Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

Forms and Documents

Document Name	Status
Form CMS-10371 SBM Three-year Budget Reports Form and Instruction	New
Form CMS-10371 SBM Individual Market Reports (weekly and monthly) Form and Instruction	New
Form CMS-10371 Budget Report Form and Instruction	Modified
Form CMS-10371 Implementation Review Form and Instruction	Removed
Form CMS-10371 Weekly Reports Form and Instruction	Removed
Form CMS-10371 Monthly Reports Form and Instruction	Removed
Form CMS-10371 Annual Report Form and Instruction	Unchanged
Form CMS-10371 Quarterly Reports Form and Instruction	Modified
Form CMS-10371 Work Plan Update Form and Instruction	Removed
Form CMS-10371 Semi-Annual Reports Form and Instruction	Modified
Form CMS-10371 Public - Progress Reports Form and Instruction	Removed
OMB_0938-1119 - Supporting Statement_30-day_Final.docx Supporting Statement A	2017-08-24

IC Document Collections

IC ID	Document Title	Status
228022	SBM Three-year Budget Reports Form and Instruction	New
228019	SBM Individual Market Reports (weekly and monthly) Form and Instruction	New
216248	Budget Report Form and Instruction	Modified
208348	Implementation Review Form and Instruction	Removed
208346	Weekly Reports Form and Instruction	Removed
208345	Monthly Reports Form and Instruction	Removed
208344	Annual Report Form and Instruction	Unchanged
208343	Quarterly Reports Form and Instruction	Modified
198691	Work Plan Update Form and Instruction	Removed
198690	Semi-Annual Reports Form and Instruction	Modified
198689	Public - Progress Reports Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 201708-0938-014
Status: Historical Active	Previous ICR Reference No: 201504-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: 20357
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)
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: 10/05/2017
	Date Received in OIRA: 08/31/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved	05/31/2018
Responses	554	0	1,080
Time Burden (Hours)	12,328	0	30,731
Cost Burden (Dollars)	0	0	0

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Abstract: Information collected as a part of the application for this grant will be used to evaluate the applications and determine awardees. Information collected pursuant to the reporting requirements for awardees will be used to evaluate the progress of States in planning for and implementing Exchanges, and determine how the Secretary can provide assistance to achieve the goals of the grant program and the Affordable Care Act.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1311 Name of Law: Affordable choices of health benefit plans
  

Citations for New Statutory Requirements: None

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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:
	82 FR 23007	05/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 40157	08/24/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Work Plan Update	CMS-10371	Establishment Review - Work Plan Update
Monthly Reports	CMS-10371, CMS-10371	Monthly Progress Report ,   Monthly Progress Report Data Elements
Budget Report	CMS-10371	Budget Report
Quarterly Reports	CMS-10371	Quarterly Template
Annual Report	CMS-10371, CMS-10371	Annual Report Template ,   Annual Reporting Data Elements
Semi-Annual Reports	CMS-10371	Establishment Review - Semi-Annual
SBM Three-year Budget Reports	CMS-10371	SBM Three-Year Budget Template
Public - Progress Reports	CMS-10371, CMs-10371	Progress Report ,   Progress Report
Implementation Review	CMS-10371	Exchange Establishment Grant FOA
Weekly Reports	CMS-10371	Weekly Report
SBM Individual Market Reports (weekly and monthly)	CMS-10371	SBM Individual Market Reporting

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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	554	1,080	0	0	-526	0
Annual Time Burden (Hours)	12,328	30,731	0	0	-18,403	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 revision removes the workplan, public report, and implementation review reporting requirements. It also the amends the number of respondents for the semi-annual and budget reports to reflect the current number of active grantees. Updates to reporting metrics for the SBM Individual Market (formerly known as Weekly and Monthly Periodic) reports results in a net decrease of 192 metrics. The changes to the Quarterly Periodic reports results in a net decrease of 332 metrics. The addition of the SBM three-year budget report adds 272 hours to this package. Thus, there is a total net reduction of 18,403 hours.

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Annual Cost to Federal Government: $121,350

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? 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: 08/31/2017

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