Application for Coverage in the Pre-Existing Condition Insurance Plan

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
193406	Premium Payment (2013)	New
193405	Application and Eligibility (2013)	New
193404	Premium Payment (2012)	New
193403	Application and Eligibility (2012)	New
193402	Premium Payment (2011)	New
193401	Application and Eligibility (2011)	New
193400	Premium Payment (2010)	New
193399	Application and Eligibility (2010)	New

ICR Details

OMB Control No: 0938-1095	ICR Reference No: 201006-0938-012
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application for Coverage in the Pre-Existing Condition Insurance Plan
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: 06/28/2010
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/29/2010
	Date Received in OIRA: 06/25/2010
Terms of Clearance: This information collection request is approved consistent with revisions made on June 29th. HHS will update this approval with via a change worksheet to incorporate the final approved, formatted versions in both English and Spanish.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	6 Months From Approved
Responses	399,999	0	0
Time Burden (Hours)	233,999	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The data collection will be used by HHS to obtain information from potential eligible individuals applying for coverage in the PCIP. On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act (Affordable Care Act), Public Law 111-148. Section 1101 of the law establishes a "temporary high risk health insurance pool program" (which has been named the Pre-Existing Condition Insurance Plan, or PCIP) to provide health insurance coverage to currently uninsured individuals with pre-existing conditions. The law authorizes HHS to carry out the program directly or through contracts with states or private, non-profit entities.

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: Immediate access to insurance for uninsured individuals with a preexisting
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1101 Name of Law: Immediate access to insurance for uninsured individuals with a preexisting

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking
	Other Documents for OIRA Review

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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: 8

IC Title	Form No.	Form Name
Premium Payment (2012)	CMS-10334
Application and Eligibility (2013)	CMS-10334
Premium Payment (2013)	CMS-10334
Application and Eligibility (2010)	CMS-10334
Premium Payment (2010)	CMS-10334
Application and Eligibility (2011)	CMS-10334
Premium Payment (2011)	CMS-10334
Application and Eligibility (2012)	CMS-10334

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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	399,999	0	399,999	0	0	0
Annual Time Burden (Hours)	233,999	0	233,999	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 request.

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Annual Cost to Federal Government: $20

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: 06/25/2010

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