CMS-10428_Supporting_Statement_Part_A508

Supporting Statement – PCIP Authorization to Share Personal
Health Information
A.

Justification

1. Circumstances Making the Collection of Information Necessary
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.
The Department of Health and Human Services (HHS) Centers for Medicare & Medicaid
Services, Center for Consumer Information and Insurance Oversight is requesting clearance
by the Office of Management and Budget for this new collection package. This new package
is being requested as a result of CMS, in its administration of the PCIP program, serving as a
covered entity under the Health Insurance Portability and Accountability Act (HIPAA).
Without a valid authorization, the PCIP program is unable to disclose information, with
respect to an applicant or enrollee, about the status of an application, enrollment, premium
billing or claim, to individuals of the applicant’s or enrollee’s choosing. The HIPAA
Authorization Form has been modeled after CMS’ Medicare HIPAA Authorization Form
(OMB control number 0938-0930) and will be used by applicants or enrollees to designate
someone else to communicate with PCIP about their protected health information (PHI).
2. Purpose and Use of Information Collection
Unless permitted or required by law, the Health Insurance Portability and Accountability Act
(HIPAA) Privacy Rule (§ 164.508) prohibits CMS’ PCIP program (a HIPAA covered entity)
from disclosing an individual’s protected health information without a valid authorization. In
order to be valid, an authorization must include specified core elements and statements.
CMS will make available to PCIP applicants and enrollees a standard, valid authorization to
enable beneficiaries to communicate with PCIP about their personal health information. This
is a critical tool because the population the PCIP program serves is comprised of individuals
with pre-existing conditions who may be incapacitated and need an advocate to help them
apply for or receive benefits from the program. This standard authorization will simplify the
process of requesting information disclosure for beneficiaries and minimize the response
time for the PCIP program.

1

3. Use of Improved Information Technology and Burden Reduction
The HIPAA authorization form may be submitted via fax, United States mail or
electronically, at the consumers’ discretion. Information will be collected from individuals
with varying access to electronic devices and therefore requiring all individuals to submit
information electronically would restrict individuals from being able to designate an
authorized representative to speak with the PCIP program on their behalf.
4. Efforts to Identify Duplication and Use of Similar Information
The HIPAA Authorization Form has been modeled after CMS’ Medicare HIPAA
Authorization Form (OMB control number 0938-0930). CMS made minimal changes to the
existing HIPAA Authorization Form to make the form applicable to its PCIP program
beneficiaries.
5. Impact on Small Businesses or Other Small Entities
No impact on small business.
6. Consequences of Collecting the Information Less Frequently
Information collected is a one-time data collection.
7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
No special circumstance.
8. Comments in Response to the Federal Register Notice/Outside Consultation
CMS solicited public comment by 60-day Federal Register notice on July 7, 2012 (77 FR
58558). No comments were received in response to the notice.
9. Explanation of any Payment/Gift to Respondents
Not applicable.
10. Assurance of Confidentiality Provided to Respondents
All information will be kept private to the extent allowed by application laws/regulations.
11. Justification for Sensitive Questions
There are no sensitive questions.

2

12. Estimates of Annualized Burden Hours (Total Hours & Wages)
Each individual will be asked to complete the form which will include providing the
individual’s name, PCIP account number (if known), date of birth, what personal health
information they agree to share, the length of time the individual agrees their personal health
information can be shared, the names and addresses of the third party the individual wants
PCIP to share their personal health information with, and an attestation that the individual is
giving PCIP permission to share their personal health information with the third party listed
in the form. This completed form will be submitted to the PCIP benefits administrator,
GEHA, which contracts with CMS.
We estimate that it will take approximately 15 minutes per applicant to complete and submit
a HIPAA Authorization Form to the PCIP program.
The federally-run PCIP program operates in 23 states plus the District of Columbia and
receives an average of 35,000 enrollment applications per year1. To estimate the number of
PCIP applicants and enrollees who may complete an authorization, we looked at the
percentage of individuals who request an authorization in Medicare as a baseline. Medicare
estimates 3% of its population will submit an authorization per year2. However, since the
PCIP program caters to an exclusive population comprised of individuals who have one or
more pre-existing conditions, we believe it is likely we could receive double the percentage
estimated by Medicare. Accordingly, PCIP estimates 6% (or 2,100)3 of its applicants and
enrollees may submit an authorization per year.
Based on the above, it is estimated that up to 2,100 applicants and enrollees may submit an
authorization annually. There is no cost to PCIP beneficiaries to request, complete, submit,
or have the authorization form processed by PCIP. It should take approximately 15 minutes
for a beneficiary to complete the authorization form. 15 minutes multiplied by 2,100
beneficiaries equals 525 hours.

3

12A. Estimated Annualized Burden Hours
Estimated Annualized Burden Table for 2012
Forms
(If necessary)

Type of
Respondent

Complete &
Submit Form
Total

Individual

Number of
Number of
Average
Respondents Responses per Burden
Respondent
hours per
Response
2,100
1
.25

Total
Burden
Hours

525
525

.25

Estimated Annualized Burden Table for 2013
Forms
(If necessary)

Type of
Respondent

Complete &
Submit Form
Total

Individual

Number of
Number of
Average
Respondents Responses per Burden
Respondent
hours per
Response
2,100
1
.25

Total
Burden
Hours

525
525

.25

Estimated Annualized Burden Table for 2014
Forms
(If necessary)

Type of
Respondent

Complete &
Submit Form
Total

Individual

Number of
Number of
Average
Respondents Responses per Burden
Respondent
hours per
Response
2,100
1
.25
.25

Total
Burden
Hours

525
525

12B. Cost Estimate for All Respondents Completing the Letter of Intent and
Contact Information
We have calculated the estimated burden hours associated with complying with this information
collection request. However, we do not believe the respondents will incur any cost burden
above other than that associated with mailing the authorization. There is no cost to PCIP
beneficiaries to request, complete, or have the authorization processed by PCIP.

4

Authorization Process
In order to complete the authorization, each individual will need to read the authorization, fill out
the required information in the authorization form, make a copy for themselves, and submit the
completed authorization to the PCIP benefits administrator. This burden estimate encompasses
the entire process of filling out the authorization which includes completing the individual’s
name, PCIP account number, date of birth, what personal health information they agree to share,
the length of time the individual agrees their personal health information can be shared, the
names and addresses of the third party the individual wants PCIP to share their personal health
information with, and an attestation that the individual is giving PCIP permission to share their
personal health information with the third party listed in the form. The completed authorization
must be submitted to CMS, either by fax, United States mail or electronically.
We estimate that it will take approximately 15 minutes for a beneficiary to read, complete, and
submit the authorization form to the PCIP benefits administrator.
It is estimated that up to 2,100 respondents will submit an authorization
.
13. Estimates of other Total Annual Cost Burden to Respondents or Record Keepers
/Capital Costs
There are no capital costs for respondents or recordkeepers.
14. Annualized Cost to Federal Government
Cost to government to review the program.
Type
Federal
employee
support

Total
Burden
Hours

First level
reviewer
Total

1

Hourly
Wage Rate (GS 7
equivalent)

Total Federal
Government Costs

$20.22

1

$20.22
$20.22

Salaries are based on a 7 Grade/Step 1 in Washington DC area.
15. Explanation for Program Changes or Adjustments

16. Plans for Tabulation and Publication and Project Time Schedule
Data collection will begin as soon as clearance is received and will be collected daily,
5

through 2014. While the program terminates January 1, 2014 upon transition to the
American Health Benefit Exchanges, (established under sections 1311 or 1321 of the Patient
Protection and Affordable Care Act) it is expected this form could be used through 2014
while program claims incurred in 2013 continue to be adjudicated.
17. Reason(s) Display of OMB Expiration Date is Inappropriate
Not applicable.

B. Collection of Information Employing Statistical Methods
Not applicable. The information collection does not employ statistical methods.

1

This figure is based on internal application statistics. Applications received do not always equate to an enrollment.
However, because an applicant may submit an authorization this larger figure was used.
2
Based on Medicare’s PRA package (OMB control number 0938-0930) estimating out of 39 million Medicare
beneficiaries that approximately 1 million (or 3%) would submit authorizations.
3
6% of 35,000 average applications received per year equals 2,100 authorizations

6