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View Information Collection (IC) List
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1095
ICR Reference No:
201106-0938-014
Status:
Historical Active
Previous ICR Reference No:
201104-0938-001
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Application for Coverage in the Pre-Existing Condition Insurance Plan
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
06/15/2011
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/15/2011
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2013
12/31/2013
12/31/2013
Responses
399,999
0
399,999
Time Burden (Hours)
233,999
0
233,999
Cost Burden (Dollars)
0
0
0
Abstract:
The data collection will be used by HHS to obtain information from potential eligible individuals applying for coverage in the PCIP. 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.
Authorizing Statute(s):
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
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0991-AB71
Final or interim final rulemaking
75 FR 45014
07/30/2010
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
8
IC Title
Form No.
Form Name
Application and Eligibility (2010)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish
,
CMS-10334.DRAFT Federal fallback enrollment form
Application and Eligibility (2011)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Application and Eligibility (2012)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Application and Eligibility (2013)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Premium Payment (2010)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Premium Payment (2011)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Premium Payment (2012)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
Premium Payment (2013)
CMS-10334, CMS-10334
PreExistingConditionPlan_EnrollmentForm_Spanish_508
,
CMS-10334.DRAFT Federal fallback enrollment form
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
399,999
399,999
0
0
0
0
Annual Time Burden (Hours)
233,999
233,999
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:
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
Agency Contact:
William Parham 4107864669
Common Form ICR:
No
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:
06/15/2011
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