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:
202506-0938-003
Status:
Historical Inactive
Previous ICR Reference No:
202504-0938-017
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:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Comment filed on proposed rule and continue
Conclusion Date:
07/07/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/04/2025
Terms of Clearance:
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OIRA a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2027
36 Months From Approved
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:
0938-AV61
Proposed rulemaking
90 FR 12942
03/19/2025
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
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
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:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
There is a total annual application processing burden increase of 2,554,446 hours (from 2,112,493 hours to 4,666,939 hours). The burden increase is due to the increase in consumers for whom the Exchange will need to adjudicate income inconsistencies and process SEP verification issues. There is a total annual consumer burden increase of 2,026,150 hours (from 4,992,959 hours to 7,019,109 hours). The burden increase is due to the increase in consumers who will need to gather and submit documents in order to adjudicate income inconsistencies and resolve SEP verification issues.
Annual Cost to Federal Government:
$3,629,229
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:
06/04/2025
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