Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (CMS-10416)

Forms and Documents

Document Name	Status
Form CMS-10416 Exchange Blueprint Application Form and Instruction	Modified
PRA Cross-Walk_Blueprint 2025.docx Supplementary Document	2025-08-29
CMS-10416 - Blueprint Supporting Statement (Clean).docx Supporting Statement A	2025-08-29

IC Document Collections

IC ID	Document Title	Status
202391	Exchange Blueprint Application Form and Instruction	Modified

ICR Details

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	09/30/2025
Responses	2	4
Time Burden (Hours)	107	126
Cost Burden (Dollars)	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: 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:
	90 FR 3871	01/15/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 42013	08/28/2025
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Exchange Blueprint Application	CMS-10416	Blueprint for Approval of Affordable Healthcare Marketplaces

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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	2	4	0	0	-2	0
Annual Time Burden (Hours)	107	126	0	0	-19	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: 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.

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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

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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: 08/29/2025

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