Patient Protection and Affordable Care Act; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors; Exchange and Insurance Market Standards for 2015

Forms and Documents

Document Name	Status
Form CMS-10472 Consumer authorization forms Form and Instruction	New
Form CMS-10472 Training Registration Form and Instruction	New
CMS-10472 - Supporting Statement Part A Revised Nav non-Nav clean.docx Supporting Statement A	2015-04-27
CMS-10472 Supporting Statement Part B.PDF Supporting Statement B	2015-04-27

IC Document Collections

IC ID	Document Title	Status
216292	Consumer authorization forms Form and Instruction	New
216291	Certification and Recertification	New
216289	Training Registration Form and Instruction	New
207835	Conflict of Interest	Modified

ICR Details

OMB Control No: 0938-1220	ICR Reference No: 201504-0938-014
Status: Historical Active	Previous ICR Reference No: 201307-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: 19996
Title: Patient Protection and Affordable Care Act; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors; Exchange and Insurance Market Standards for 2015
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/27/2015
	Date Received in OIRA: 04/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	01/31/2017
Responses	944,130	0	45,279
Time Burden (Hours)	1,087,878	0	528,678
Cost Burden (Dollars)	0	0	0

---

Abstract: Navigators as well as non-Navigator assistance personnel fulfilling the requirements of 45 CFR 155.205(d) and (e) in Federally-facilitated Exchanges have to provide an attestation to the Exchange that they are not ineligible to serve as a Navigator or non-Navigator assistance personnel. In addition, Navigators and non-Navigator assistance project leads have to prepare and submit a plan for mitigating conflicts of interest during their term as a Navigator grantee or non-Navigator assistance personnel. This mitigation plan is only required on a per entity basis, not a per individual basis. Navigators will include attestation information within their grant application through previously approved OMB covered forms, and as such, the burden for Navigators providing this information is not calculated in this PRA. Navigators and non-Navigator assistance personnel are required to provide information to eligible consumers about the full range of QHP options and insurance affordability programs for which they may be eligible. A disclosure to the Exchange and each consumer receiving assistance, about certain non-prohibited conflicts of interest, are required by Navigators and non-Navigator assistance personnel. Prior to performing any Navigator or non-Navigator assistance personnel duties, individuals are required to register for training as a prerequisite to becoming certified. After their first year performing their required duties, they will be required to be recertified. Navigators and non-Navigator assistance personnel are required to maintain proof of their certification or recertification.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1311(i) Name of Law: Navigators
  

Citations for New Statutory Requirements: None

---

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:
	80 FR 5118	01/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 21721	04/20/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Conflict of Interest
Certification and Recertification
Training Registration	CMS-10472, CMS-10472, CMS-10472	Training Quality Questionnaire ,   Sample Training Completion Certificate ,   Registration Portal
Consumer authorization forms	CMS-10472, CMS-10472	Model Authorization Form (Navigators) ,   Model Aurthorization Form - (Navigators - 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	944,130	45,279	0	0	898,851	0
Annual Time Burden (Hours)	1,087,878	528,678	0	0	559,200	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: These collection requirements are associated with 45 CFR 155.210 and 155.215. These requirements were finalized as part of a final rulemaking published on May 27, 2014 at 79 FR 30240. No changes are being made to currently approved collection requirements. The revision to this collection is due to the addition of an optional training quality questionnaire at the end of the required initial certification, and annual recertification, trainings. There was also an overall increase in hours due to a mathematical error in the previous submission.

---

Annual Cost to Federal Government: $15

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

---

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: 04/27/2015

---