Pre-Existing Condition Insurance Plan and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-10339 Proposal Modification Form and Instruction	Modified
Form CMS-10339 Record Retention Form and Instruction	Modified
Form CMS-10339 Audit Form and Instruction	Modified
Form CMS-10339 Audited Financial Report Form and Instruction	Modified
Form CMS-10339 Quarterly and Monthly Reporting Form and Instruction	Modified
state_solicitation.pdf Supplementary Document	2013-08-06
PCIP Model Contract.pdf Supplementary Document	2013-08-06
CMS-10339 Supporting_Statement_Part_A.pdf Supporting Statement A	2013-08-06

IC Document Collections

IC ID	Document Title	Status
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: 201308-0938-003
Status: Historical Active	Previous ICR Reference No: 201012-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No: 20220
Title: Pre-Existing Condition Insurance Plan and Supporting Regulations
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/20/2013
	Date Received in OIRA: 08/06/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 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.

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Authorizing Statute(s): None

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:
	78 FR 26035	05/03/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 44569	07/24/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Proposal Modification	CMS-10339, CMS-10339	State Solicitation ,   Template Contract
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	State Solicitation ,   Template Contract
Reports of Insurer Dumping (42 CFR 152.28)
Audit	CMS-10339, CMS-10339	Tempate Contract ,   State Solicitation
Record Retention	CMS-10339, CMS-10339	Template Contract ,   State Solicitation

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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	2,652	2,652	0	0	0	0
Annual Time Burden (Hours)	36,924	36,924	0	0	0	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: No

Burden Reduction Due to:

Short Statement:

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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: 08/06/2013

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