Application for Coverage in the Pre-Existing Condition Insurance Plan

ICR 201012-0938-020

OMB: 0938-1095

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Supporting Statement A
2010-12-30
ICR Details
0938-1095 201012-0938-020
Historical Active 201008-0938-016
HHS/CMS
Application for Coverage in the Pre-Existing Condition Insurance Plan
Extension without change of a currently approved collection   No
Regular
Approved without change 12/30/2010
Retrieve Notice of Action (NOA) 12/30/2010
  Inventory as of this Action Requested Previously Approved
12/31/2013 36 Months From Approved 12/31/2010
399,999 0 399,999
233,999 0 233,999
0 0 0

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.

PL: Pub.L. 111 - 148 1101 Name of Law: Immediate access to insurance for uninsured individuals with a preexisting
  
None

0991-AB71 Final or interim final rulemaking 75 FR 45014 07/30/2010

  75 FR 45014 07/30/2010
75 FR 70927 11/19/2010
No

8
IC Title Form No. Form Name
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)
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)
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)
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)
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)
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)
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)
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)

  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
No
No

$20
No
No
Yes
No
No
Uncollected
William Parham 4107864669

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/30/2010


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