Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges

Forms and Documents

Document Name	Status
Form CMS-10416 Exchange Blueprint Form and Instruction	New
Exchange Blueprint 60-Day Comment Tracking Tool_032212.xlsx Supplementary Document	2012-05-21
CMS-10416.Updated Supporting Statement_040612.docx Supporting Statement A	2012-05-21

IC Document Collections

IC ID	Document Title	Status
202391	Exchange Blueprint Form and Instruction	New

ICR Details

OMB Control No: 0938-1172	ICR Reference No: 201205-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/13/2012
	Date Received in OIRA: 05/21/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved
Responses	56	0	0
Time Burden (Hours)	11,816	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is working with States (including the District of Columbia and the territories) to establish Exchanges in every State. The law gives States the opportunity to establish State-based Exchanges, subject to approval that the State-based Exchange meets federal standards and will be ready to offer health care coverage on January 1, 2014. The deadline for Exchange approval is January 1, 2013. In a State that does not achieve Exchange approval by the deadline, the law directs the Secretary of Health and Human Services to facilitate the establishment of an Exchange in that State. States will apply for approval or conditional approval of their State Exchange in the Fall of 2012 with decisions made on January 1, 2013.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1311(b) Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1311(b) Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 70148	11/10/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 29646	05/18/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Exchange Blueprint	CMS-10416	Exchange Blueprint Revised

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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	56	0	56	0	0	0
Annual Time Burden (Hours)	11,816	0	11,816	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: This is a new information collection request.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 05/21/2012

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