Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - CAC (CMS-10494)

OMB 0938-1205

Section 1413 of the Affordable Care Act directs the Secretary of HHS to establish, subject to minimum requirements, a streamlined enrollment system for qualified health plans offered through the Exchange and insurance affordability programs. In addition, section 1321(a)(1) of the Affordable Care Act directs and authorizes the Secretary to issue regulations setting standards for meeting the requirements under title I of the Affordable Care Act, with respect to, among other things, the establishment and operation of Exchanges. Pursuant to this authority, regulations establishing the certified application counselor program are being finalized at 45 CFR 155.225. Specifically, 45 CFR 155.225(a) requires an Exchange to establish a certified application counselor program that complies with the requirements of the rule. Section155.225(b)(1) allows each Exchange to designate certain organizations, including organizations designated by state Medicaid or CHIP agencies, which will certify their staff and volunteers to act as certified application counselors. In accordance with 45 CFR 155.225(b)(2), Exchanges may choose to certify directly individuals who seek to act as certified application counselors, designate certain organizations which will certify staff or volunteers to perform application services, or do both.

The latest form for Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - CAC (CMS-10494) expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10494 Navigator Requirements for Training Certification Form and Instruction
Form CMS-10494 Certified Counselor Designated Organization (CDO Application) Form and Instruction
Form CMS-10494 Recertification request by organization Form and Instruction
Form CMS-10494 155.225(b)(1) Organization designation by Exchange Information Updates Form and Instruction
Form CMS-10494 155.225(d)(1) and (7) Training Quality Optional Questionnaire Form and Instruction
Form CMS-10494 155.225(d)(1) - Training certificate retention Form and Instruction
Form CMS-10494 155.225(d)(1) - Training certificate proof Form and Instruction
Form CMS-10494 155.225(d)(1) - Training Registration Form and Instruction
Form CMS-10494 155.225(b)(1)(ii) - Identification number record retention Form and Instruction
Form CMS-10494 155.225(b)(1)(ii) - Issuance of unique registration identification number Form and Instruction
Form CMS-10494 155.225(d)(2) and (f) (CAC authorization to consumer) Form and Instruction
Form CMS-10494 155.225(b)(1)(i) (certificate issuance) Form and Instruction
Form CMS-10494 155.225(b)(1) (organization follow-up for application) Form and Instruction
Form CMS-10494 155.225(b)(1) (organization designation by Exchange) Form and Instruction
CMS-10494 - Conflict of Interest Disclosure_ CAC).pdf Supplementary Document
CMS-10494 - Non Substantive Change Request 508.pdf Justification for No Material/Nonsubstantive Change
CMS-10494 - Supporting_Statement_March 2022.docx Supporting Statement A
Navigator Requirements for Training Certification Form and Instruction
Certified Counselor Designated Organization (CDO Application) Form and Instruction
?155.225 (b)(ii) (performance tracking form by organization)
?155.225 (b)(ii) (reporting performance data by certified application counselor)
?155.225 (b)(ii) (recordkeeping performance data by organization)
?155.225 (b)(1)(iii)- (reporting by organizations)
?155.225 (b)(1)(iii)- (review by State Exchange)
?155.225(b)(1)(iii)-(review byFederally-facilitatedExchange)
Recertification Training
Recertification request by organization Form and Instruction
CAC Recertification
155.225(b)(1) Organization designation by Exchange Information Updates Form and Instruction
155.225(d)(1) and (7) Training Quality Optional Questionnaire Form and Instruction
155.225(d)(1) - Training certificate retention Form and Instruction
155.225(d)(1) - Training certificate proof Form and Instruction
155.225(d)(1) - Training Registration Form and Instruction
155.225(b)(1)(ii) - Identification number record retention Form and Instruction
155.225(b)(1)(ii) - Issuance of unique registration identification number Form and Instruction
155.225(d)(2) and (f) (CAC authorization to consumer) Form and Instruction
155.225(d)(2) and (f) (organization record of authorization)
155.225(b)(1)(i) (certificate issuance) Form and Instruction
155.225(b)(1) (organization list)
155.225(b)(1)(i) (organization attestation)
155.225(b)(1) (organization follow-up for application) Form and Instruction
155.225(b)(1) (organization designation by Exchange) Form and Instruction

All Historical Document Collections

202210-0938-013 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-10-25
202110-0938-014 Approved with change	Revision of a currently approved collection	2021-11-03
201810-0938-013	Revision of a currently approved collection	2020-03-31
201703-0938-005 Approved with change	Revision of a currently approved collection	2017-03-13
201603-0938-001 Comment filed on proposed rule and continue	Revision of a currently approved collection	2016-03-02
201504-0938-012 Approved without change	Revision of a currently approved collection	2015-04-24
201407-0938-001 Comment filed on proposed rule and continue	Revision of a currently approved collection	2014-07-03
201308-0938-016 Approved without change	Revision of a currently approved collection	2013-08-15
201307-0938-015 Approved with change	New collection (Request for a new OMB Control Number)	2013-07-23

OMB Details

155.225(b)(1) (organization designation by Exchange)

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10494

Individual CAC Agreement

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.