Pre-Existing Condition Insurance Plan and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-10339 Proposal Modification Form and Instruction	New
Form CMS-10339 Record Retention Form and Instruction	New
Form CMS-10339 Audit Form and Instruction	New
Form CMS-10339 Audited Financial Report Form and Instruction	New
Form CMS-10339 Quarterly and Monthly Reporting Form and Instruction	New
CMS-10339.HHS Template Contract.docx Supplementary Document	2010-07-26
CMS-10339.state_solicitation.pdf Supplementary Document	2010-07-26
CMS-10339.Supporting Statement Part A-7-26-10.docx Supporting Statement A	2010-07-26

IC Document Collections

IC ID	Document Title	Status
193926	Proposal Modification Form and Instruction	New
193925	Record Retention Form and Instruction	New
193924	Audit Form and Instruction	New
193923	Reports of Insurer Dumping (42 CFR 152.28)	New
193922	Audited Financial Report Form and Instruction	New
193921	Quarterly and Monthly Reporting Form and Instruction	New
193920	Fraud, Waste, and Abuse (42 CFR 152.27)	New
193919	Payment Invoices (42 CFR 152.32)	New

ICR Details

OMB Control No: 0938-1100	ICR Reference No: 201012-0938-019
Status: Historical Active	Previous ICR Reference No: 201007-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Pre-Existing Condition Insurance Plan and Supporting Regulations
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/30/2010
	Date Received in OIRA: 12/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	6 Months From Approved
Responses	2,652	0	0
Time Burden (Hours)	36,924	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of Health and Human Services is requesting emergency action for clearance by the Office of Management and Budget no later than 07/26/10. We are requesting emergency processing procedures for this package because this information is needed immediately to assure that Pre-Existing Condition Insurance Plan (PCIP) programs are established timely and effectively. This request is being made based on regulations to be issued and contracts to be executed by states or an entity on their behalf participating in the PCIP program. PCIP is also referred to as the temporary qualified high risk insurance pool program, as it is called in the Affordable Care Act, but we have adopted the term PCIP to better describe the program and avoid confusion with the existing state high risk pool programs.

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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 condition
  

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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0991-AB71	Final or interim final rulemaking	75 FR 45014	07/30/2010

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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
Payment Invoices (42 CFR 152.32)
Fraud, Waste, and Abuse (42 CFR 152.27)
Quarterly and Monthly Reporting	CMS-10339, CMS-10339	Deliberative Document ,   Deliberative Document
Audited Financial Report	CMS-10339, CMS-10339	Deliberative Document ,   Deliberative Document
Reports of Insurer Dumping (42 CFR 152.28)
Audit	CMS-10339, CMS-10339	Deliberative Document ,   Deliberative Document
Record Retention	CMS-10339	Deliberative Document
Proposal Modification	CMS-10339, CMS-10339	Deliberative Document ,   Deliberative Document

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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	2,652	0	2,652	0	0	0
Annual Time Burden (Hours)	36,924	0	36,924	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: $2,000

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: 07/26/2010

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