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	Modified
Form CMS-10371 SBM Individual Market Reports (weekly) Form and Instruction	Modified
Form CMS-10371 Annual Report Form and Instruction	Removed
Form CMS-10371 Quarterly Reports Form and Instruction	Removed
Form CMS-10371 Semi-Annual Reports Form and Instruction	Removed
CMS-10371 - Cooperative Agreement Supporting Statement (F).docx Supporting Statement A	2022-04-08

IC Document Collections

IC ID	Document Title	Status
252604	State Based Marketplace Data Collection Templates for Bi-Annual Reporting Other-Data Template	New
228022	SBM Three-year Budget Reports Form and Instruction	Modified
228019	SBM Individual Market Reports (weekly) Form and Instruction	Modified
216248	End of Enrollment Budget Report Other-Data Elements	Modified
208344	Annual Report Form and Instruction	Removed
208343	Quarterly Reports Form and Instruction	Removed
198690	Semi-Annual Reports Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 202203-0938-011
Status: Received in OIRA	Previous ICR Reference No: 201708-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/12/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	273	0
Time Burden (Hours)	2,821	0
Cost Burden (Dollars)	1,251,236	0

---

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.

---

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

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:
	85 FR 55460	09/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 16740	03/24/2022
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
Annual Report	CMS-10371, CMS-10371	Annual Report Template ,   Annual Reporting Data Elements
End of Enrollment Budget Report
Quarterly Reports	CMS-10371	Quarterly Template
SBM Individual Market Reports (weekly)	CMS-10371	SBM Individual Market Reporting
SBM Three-year Budget Reports	CMS-10371	SBM Three-Year Budget Template
Semi-Annual Reports	CMS-10371	Establishment Review - Semi-Annual
State Based Marketplace Data Collection Templates for Bi-Annual Reporting

---

ICR Summary of Burden

	Total Request	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	273	0	0	0	-281	554
Annual Time Burden (Hours)	2,821	0	0	0	-9,507	12,328
Annual Cost Burden (Dollars)	1,251,236	0	0	0	1,251,236	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 overall burden hours for this approval decreased because certain grant periodic reporting requirements were removed, eliminating approximately 78% of the total costs from the previously approved estimates. CMS also accounted for an increase in the number of SBE and SBE-FPs (from 15 to 21), which increased the total three-year burden hours for the four reports remaining in this package from 5,784 to 8,460 (or 2,821 hours annually).

---

Annual Cost to Federal Government: $68,138

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

---

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: 04/12/2022

---