Application for Coverage in the Pre-Existing Condition Insurance Plan

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)	Form and Instruction	Modified	Repair queued
Form CMS-10334 Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)	Form and Instruction	Modified	Available
CMS-10334.Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2010-12-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193406	Premium Payment (2013)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193406	Premium Payment (2013)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193405	Application and Eligibility (2013)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193405	Application and Eligibility (2013)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193404	Premium Payment (2012)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193404	Premium Payment (2012)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193403	Application and Eligibility (2012)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193403	Application and Eligibility (2012)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193402	Premium Payment (2011)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193402	Premium Payment (2011)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193401	Application and Eligibility (2011)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193401	Application and Eligibility (2011)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193400	Premium Payment (2010)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193400	Premium Payment (2010)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)
193399	Application and Eligibility (2010)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
193399	Application and Eligibility (2010)	Form and Instruction	Modified	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version)

ICR Details

OMB Control No: 0938-1095	ICR Reference No: 201012-0938-020
Status: Historical Active	Previous ICR Reference No: 201008-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application for Coverage in the Pre-Existing Condition Insurance Plan
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/30/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/30/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	36 Months From Approved	12/31/2010
Responses	399,999	0	399,999
Time Burden (Hours)	233,999	0	233,999
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.

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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: None

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 45014	07/30/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 70927	11/19/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Application and Eligibility (2010)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2011)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2012)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Application and Eligibility (2013)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2010)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2011)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2012)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)
Premium Payment (2013)	CMS-10334, CMS-10334	Application for Coverage in the Pre-Existing Condition Insurance Plan (English Version) ,   Application for Coverage in the Pre-Existing Condition Insurance Plan (Spanish Version)

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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	399,999	399,999	0	0	0	0
Annual Time Burden (Hours)	233,999	233,999	0	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:

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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]? No

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: 12/30/2010

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