View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1191
ICR Reference No:
202504-0938-017
Status:
Active
Previous ICR Reference No:
202409-0938-029
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CCIIO
Title:
Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
05/02/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/18/2025
Terms of Clearance:
Prior to the next extension or revision of this ICR, the public burden statement on each instrument shall be updated to include language that provides all of the information required per 5 CFR ยง 1320.8(b)(3).
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2027
09/30/2027
09/30/2027
Responses
11,327,040
0
11,327,040
Time Burden (Hours)
7,105,452
0
7,105,452
Cost Burden (Dollars)
0
0
0
Abstract:
Section 1413 of the Affordable Care Act directs the Secretary of HHS to develop and provide to each State a single, streamlined form that may be used to apply for coverage through the Exchange and Insurance Affordability Programs. A state may develop and use its own single streamlined application if approved by the Secretary in accordance with section 1413 and if it meets the standards established by the Secretary.
Authorizing Statute(s):
PL:
Pub.L. 111 - 148 1413
Name of Law: Affordable Care Act
PL:
Pub.L. 111 - 152 1314
Name of Law: Health Care and Education Reconciliation Act of 2010
Citations for New Statutory Requirements:
PL: Pub.L. 111 - 148 1413 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 152 1341 Name of Law: Health Care and Education Reconciliation Act of 2010
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
89 FR 16580
03/07/2024
30-day Notice:
Federal Register Citation:
Citation Date:
89 FR 57417
07/15/2024
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Individual Application
CMS-10440, CMS-10440, CMS-10440, CMS-10440, CMS-10440, CMS-10440, CMS-10440
Application for Health Coverage & Help Paying Costs (Short Form)
,
Application for Health Coverage & Help Paying Costs
,
Application for Health Coverage (no cost help)
,
Electronic application.
,
Application for Health Coverage & Help Paying Costs (Short Form) - Spanish
,
Application for Health Coverage & Help Paying Costs - Spanish
,
Application for Health Coverage (no cost help) - Spanish
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
11,327,040
11,327,040
0
0
0
0
Annual Time Burden (Hours)
7,105,452
7,105,452
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$313,565
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Yes
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Jamaa Hill 301 492-4190
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
04/18/2025
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