Temporary High Risk Pool Program (CMS-10319)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10319 Submission of Contact Information	Form and Instruction	New	Repair queued
Form CMS-10319 Letter of Intent	Form and Instruction	New	Available
CMS-10319.Emergency Justification.docx	Supplementary Document	Uploaded 2010-04-21	Available
CMS-10319.Supporting Statement Part A.doc	Supporting Statement A	Uploaded 2010-04-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192667	Submission of Contact Information	Form and Instruction	New
192666	Letter of Intent	Form and Instruction	New

ICR Details

OMB Control No: 0938-1085	ICR Reference No: 201004-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Temporary High Risk Pool Program (CMS-10319)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/23/2010
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/21/2010
	Date Received in OIRA: 04/21/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2010	6 Months From Approved
Responses	102	0	0
Time Burden (Hours)	204	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The data collection will be used by HHS to request that States and the District of Columbia submit the following: o A primary contact person; o A letter of intent indicating whether or not they intend to submit an application to contract with HHS to operate a high risk pool program under the Affordable Care Act. As part of the letter of intent, we will request they include the anticipated timing for establishment of the program and information on any State legislative decisions that would be needed in order to participate in the new high risk pool program; o Advance indication of which of the potential implementation options appears to be most likely for states to use to carry out their program, including available additional details such as outlines of programs, or other ideas about potential mechanisms of providing coverage under the new law; and o All of the above information be submitted via email to HHS with the subject line "Notice of Intent." This above information will assist HHS in planning for and executing contracts with States to provide a high risk pool program.

Emergency Justfication: In accordance with Section 1101 of The Patient Protection and Affordability Care Act, H.R. 3590 the U.S. Department of Health and Human Services (HHS) is tasked with establishing a "temporary high risk health insurance pool program" to provide health insurance coverage to currently uninsured individuals with pre-existing conditions. This temporary high risk health insurance pool program has a statutory implementation date of July 1, 2010. Due to the urgency and the short time frames associated with this requirement, HHS does not have sufficient time to follow the normal notice and comment periods associated with the normal OMB approval process. Therefore, we are requesting an emergency review and approval for this information collection request.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1101 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1101 Name of Law: Patient Protection and 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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Letter of Intent	CMS-10319	Appendix A
Submission of Contact Information	CMS-10319	Appendix A

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ICR Summary of Burden

table that charts list 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	102	0	102	0	0	0
Annual Time Burden (Hours)	204	0	204	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.

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Annual Cost to Federal Government: $25

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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: 04/21/2010

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