Temporary High Risk Pool Program (CMS-10319)

Forms and Documents

Document Name	Status
Form CMS-10319 Solicitation and Contractor's Proposal Process Form and Instruction	Modified
Form CMS-10319 Submission of Contact Information Form and Instruction	Removed
Form CMS-10319 Letter of Intent and Submission of Contact Information Form and Instruction	Modified
CMS-10319.Supporting Statement Part A.docx Supporting Statement A	2011-03-27

IC Document Collections

IC ID	Document Title	Status
192807	Solicitation and Contractor's Proposal Process Form and Instruction	Modified
192667	Submission of Contact Information Form and Instruction	Removed
192666	Letter of Intent and Submission of Contact Information Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1085	ICR Reference No: 201103-0938-017
Status: Historical Active	Previous ICR Reference No: 201005-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Temporary High Risk Pool Program (CMS-10319)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/31/2011
	Date Received in OIRA: 03/31/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved	05/31/2011
Responses	4	0	153
Time Burden (Hours)	1,376	0	34,884
Cost Burden (Dollars)	0	0	0

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Abstract: The revised data collection will include requirements outlined in both the regulation and the application to submit the following: o The application for a state or its designated entity to request participation in the temporary high risk pool program; o Contract acceptance for those states or its designated entity who submit an acceptable application to HHS; o Payment invoices; o Reporting requirements; o Dumping reporting requirements; and o Audit requirements. This above information will assist HHS in planning for and executing contracts with States to provide a high risk pool program.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1101 Name of Law: Patient Protection and Affordable Care Act
  

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:
	75 FR 66766	10/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 16792	03/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Letter of Intent and Submission of Contact Information	CMS-10319	Appendix A
Solicitation and Contractor's Proposal Process	CMS-10319	CMS-10319.Full Solicitation for State Proposals
Submission of Contact Information	CMS-10319	Appendix A

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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	4	153	0	-51	-98	0
Annual Time Burden (Hours)	1,376	34,884	0	1,376	-34,884	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We are revising this data collection to calculate burden for the possible, but unique occasion, where a State may request that administration of the PCIP program in their State be transitioned from HHS to the State. The original data collection was intended to be a one-time data collection. However, in the course of executing contracts and speaking with each State, there were a couple of States that expressed a potential interest to HHS in possibly administering the plan in their State in the future. This revised data collection is designed to calculate burden only in those unique instances where HHS may consider a request from a State to transition from administration by HHS to administration by a State. Accordingly, this is not an expansion of the data collection but instead a renewal of and modification for those unique circumstances that may arise between now and January 1, 2014 when the program terminates upon transition to the American Health Benefit Exchanges. Also, the requirements associted with contract acceptance, payment invoices, reporting requirements, reports of dumping, and audits are now covered under OMB control number 0938-1100.

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Annual Cost to Federal Government: $4,000

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: 03/31/2011

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