Pre-Existing Condition Insurance Plan and Supporting Regulations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10339 Portability Requirements - Individual	Form and Instruction	New	Available
Form CMS-10339 Portabilty Requirements - Government	Form and Instruction	New	Available
Form CMS-10339 Proposal Modification	Form and Instruction	Modified	Available
Form CMS-10339 Record Retention	Form and Instruction	Modified	Available
Form CMS-10339 Audit	Form and Instruction	Modified	Available
Form CMS-10339 Audited Financial Report	Form and Instruction	Modified	Available
Form CMS-10339 Quarterly and Monthly Reporting	Form and Instruction	Modified	Available
CMS-10339 Emergency Justification.docx	Supplementary Document	Uploaded 2011-02-10	Available
CMS-10339.Supporting Statement Part A (clean).docx	Supporting Statement A	Uploaded 2011-02-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
196170	Portability Requirements - Individual	Form and Instruction	New
196169	Portabilty Requirements - Government	Form and Instruction	New
193926	Proposal Modification	Form and Instruction	Modified
193925	Record Retention	Form and Instruction	Modified
193924	Audit	Form and Instruction	Modified
193923	Reports of Insurer Dumping (42 CFR 152.28)		Modified
193922	Audited Financial Report	Form and Instruction	Modified
193921	Quarterly and Monthly Reporting	Form and Instruction	Modified
193920	Fraud, Waste, and Abuse (42 CFR 152.27)		Modified
193919	Payment Invoices (42 CFR 152.32)		Modified

ICR Details

OMB Control No: 0938-1100	ICR Reference No: 201102-0938-007
Status: Historical Inactive	Previous ICR Reference No: 201012-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Pre-Existing Condition Insurance Plan and Supporting Regulations
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/11/2011
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 02/15/2011
	Date Received in OIRA: 02/10/2011
Terms of Clearance: Per CMS request, this request for emergency approval is being withdrawn. Approval for the existing collection will continue.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	6 Months From Approved	12/31/2013
Responses	2,652	0	2,652
Time Burden (Hours)	36,924	0	36,924
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of Health and Human Services (HHS) is requesting an extension of this currently approved information collection request. HHS is now seeking a three-year approval for this collection. 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. We are requesting an extension for this package because this information is needed to assure that PCIP programs are established timely and effectively. This request is being made based on regulations that have been issued and contracts which have been executed by HHS with 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.

Emergency Justfication: Please see the attached emergency justification.

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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: None

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 1166	01/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 1166	01/07/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Record Retention	CMS-10339, CMS-10339	Template Contract ,   State Solicitation
Proposal Modification	CMS-10339, CMS-10339	State Solicitation ,   Template Contract
Portabilty Requirements - Government	CMS-10339	PCIP Policy Letter #3
Portability Requirements - Individual	CMS-10339	PCIP Policy Letter #3
Payment Invoices (42 CFR 152.32)
Fraud, Waste, and Abuse (42 CFR 152.27)
Quarterly and Monthly Reporting	CMS-10339, CMS-10339	State Solicitation ,   Contract Template
Audited Financial Report	CMS-10339, CMS-10339	Template Contract ,   State Solicitation
Reports of Insurer Dumping (42 CFR 152.28)
Audit	CMS-10339, CMS-10339	Tempate Contract ,   State Solicitation

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The information collection has been revised to account for the burden associated with portability requirements.

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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]? 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: 02/10/2011

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