Application for Coverage in the Pre-Existing Condition Insurance Plan

Forms and Documents

Document Name	Status
Form CMS-10334 Premium Payment Burden Form and Instruction	New
Form CMS-10334 Application and Eligibility Burden Form and Instruction	New
Form CMS-10334 Premium Payment (2013) Form and Instruction	Removed
Form CMS-10334 Application and Eligibility (2013) Form and Instruction	Removed
Form CMS-10334 Premium Payment (2012) Form and Instruction	Removed
Form CMS-10334 Application and Eligibility (2012) Form and Instruction	Removed
Form CMS-10334 Premium Payment (2011) Form and Instruction	Removed
Form CMS-10334 Application and Eligibility (2011) Form and Instruction	Removed
Form CMS-10334 Premium Payment (2010) Form and Instruction	Removed
Form CMS-10334 Application and Eligibility (2010) Form and Instruction	Removed
CMS-10334 Supporting_Statement_Part_A(CLEAN 1-30-12).docx Supporting Statement A	2012-03-20

IC Document Collections

IC ID	Document Title	Status
200521	Premium Payment Burden Form and Instruction	New
200520	Application and Eligibility Burden Form and Instruction	New
193406	Premium Payment (2013) Form and Instruction	Removed
193405	Application and Eligibility (2013) Form and Instruction	Removed
193404	Premium Payment (2012) Form and Instruction	Removed
193403	Application and Eligibility (2012) Form and Instruction	Removed
193402	Premium Payment (2011) Form and Instruction	Removed
193401	Application and Eligibility (2011) Form and Instruction	Removed
193400	Premium Payment (2010) Form and Instruction	Removed
193399	Application and Eligibility (2010) Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1095	ICR Reference No: 201112-0938-007
Status: Historical Active	Previous ICR Reference No: 201111-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application for Coverage in the Pre-Existing Condition Insurance Plan
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/20/2012
	Date Received in OIRA: 12/19/2011
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. The agency is reminded that they must review and update their supporting statements with each request. If supporting statements have not been updates, OMB will improperly submit the collection. With this revision, CMS corrects an error to the prior submission that significantly overstated the number of responses.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved	12/31/2013
Responses	83,333	0	399,999
Time Burden (Hours)	59,833	0	233,999
Cost Burden (Dollars)	0	0	0

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Abstract: An eligible individual who wishes to apply for health insurance coverage under the PCIP program must complete and submit an enrollment application. The enrollment application includes vital pieces of information used to verify the applicant is eligible for the PCIP program and enroll applicants deemed to be eligible. Individuals who have not had prior creditable coverage within the past 6 months, are a US Citizen or lawfully present, and have a pre-existing condition may apply for coverage under the PCIP program.

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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.
   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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 35445	06/17/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 56767	09/14/2011
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
Premium Payment (2011)	CMS-10334	PCIP Application
Application and Eligibility Burden	CMS-10334	PCIP Application
Application and Eligibility (2011)	CMS-10334	PCIP Application
Application and Eligibility (2012)	CMS-10334	PCIP Application
Premium Payment Burden	CMS-10334	PCIP Application
Application and Eligibility (2010)	CMS-10334	PCIP Application
Premium Payment (2010)	CMS-10334	PCIP Application
Premium Payment (2012)	CMS-10334	PCIP Application
Application and Eligibility (2013)	CMS-10334	PCIP Application
Premium Payment (2013)	CMS-10334	PCIP Application

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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	83,333	399,999	0	-399,999	83,333	0
Annual Time Burden (Hours)	59,833	233,999	0	-233,999	59,833	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden associated with this information collection request (ICR) has decreased by 233,999 hours. It has been identified as a program change because of the ROCIS system. It is an adjustment. The burden has been adjusted to correct an arithmetic error. When originally submitted, this ICR was quadruple counting the burden when instead the burden should only have been listed once as it was the estimated annual burden from year to year. The downward adjustment resulted in the correct estimated annual burden of 59,883 hours.

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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: 12/19/2011

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