Temporary High Risk Pool Program (CMS-10319)

Forms and Documents

Document Name	Status
Form CMS-10319 Application Form and Instruction	New
Form CMS-10319 Submission of Contact Information Form and Instruction	Modified
Form CMS-10319 Letter of Intent Form and Instruction	Modified
CMS-10319.Emergency Justification.docx Supplementary Document	2010-05-05
CMS-10319 Supporting Statement Part A_revision 1_final.doc Supporting Statement A	2010-05-05

IC Document Collections

IC ID	Document Title	Status
192807	Application Form and Instruction	New
192667	Submission of Contact Information Form and Instruction	Modified
192666	Letter of Intent Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1085	ICR Reference No: 201005-0938-001
Status: Historical Active	Previous ICR Reference No: 201004-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Temporary High Risk Pool Program (CMS-10319)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/06/2010
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/25/2010
	Date Received in OIRA: 05/05/2010
Terms of Clearance: This approval covers the application only. CMS will submit a separate request for approval of reporting and other burdens associated with the high risk pool program.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2010	6 Months From Approved	10/31/2010
Responses	153	0	102
Time Burden (Hours)	34,884	0	204
Cost Burden (Dollars)	0	0	0

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Abstract: The revised data collection will include requirements outlined in both the regulation and the application to submit the following: o The application for a state or its designated entity to request participation in the temporary high risk pool program; o Contract acceptance for those states or its designated entity who submit an acceptable application to HHS; o Payment invoices; o Reporting requirements; o Dumping reporting requirements; and o Audit requirements. 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: 3

IC Title	Form No.	Form Name
Letter of Intent	CMS-10319	Appendix A
Submission of Contact Information	CMS-10319	Appendix A
Application	CMS-10319	CMS - 10319 - Full Solicitation for State Proposals

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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	153	102	51	0	0	0
Annual Time Burden (Hours)	34,884	204	34,884	0	-204	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: We are revising the information collection request to include the application for the Temporary High Risk Pool Program. The burden associated with both the Letter of Intent and the Submission of Contact Information has been removed as those requirements imposed one-time burdens.

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Annual Cost to Federal Government: $48,000

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]? 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: 05/05/2010

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