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OMB Control No: 0938-1172	ICR Reference No: 202508-0938-025
Status: Received in OIRA	Previous ICR Reference No: 202207-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (CMS-10416)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/29/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2025
Responses	2	4
Time Burden (Hours)	107	126
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	2	4	-2
Annual Time Burden (Hours)	107	126	-19
Annual Cost Burden (Dollars)	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: The Office of Management and Budget (OMB) previously approved this information collection on August 31, 2022, with a total of 126 burden hours. The overall burden hours for this approval decreased because of the reduction in the number of respondents estimated over the next three years, which reduced from four to two based on the agency’s best estimate. This decreased the total annual burden hours from 126 to 106.5. Although the burden hours per respondent increased from 31.5 to 53.25 due to additional attestation requirements in the Blueprint Application information collection tool, the estimated number of respondents over the next three years has decreased, which results in an overall decrease in total burden hours.

Annual Cost to Federal Government: $109,949

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