Grants to States for Health Insurance Premium Review - Cycles I and II

Forms and Documents

Document Name	Status
Form CMS-10380 (Cycle I) Final Report Form and Instruction	New
Form CMS-10380 (Cycle II ) Final Report - end of grant Form and Instruction	Modified
Form CMS-10380 (Cycle II) Annual Report Form and Instruction	Modified
Form CMS-10380 (Cycle II) Transaction Data Collection Form and Instruction	Modified
Form CMA-10380 (Cycle II) Quarterly Report Form and Instruction	Modified
Form CMS-10380 (Cycle II) Application Form and Instruction	Modified
Form CMS-10380 (Cycle I) Application re-release Form and Instruction	Removed
Form CMS-10380 (Cycle I) Transaction Data Collection Form and Instruction	Modified
Form CMS-10380 (Cycle I) Quarterly Reports Form and Instruction	Modified
Premium Review Grants_STCs_081710.doc Supplementary Document	2011-07-26
Grant Cycle I Quarterly Report Template 8-20-10.doc Supplementary Document	2011-07-26
Grant Cycle I - Rate Review Form 2010 (V5).xlsx Supplementary Document	2011-07-26
CMS-10380.REVISED Supporting Statement Part A (7-26-11).docx Supporting Statement A	2011-07-26

IC Document Collections

IC ID	Document Title	Status
198639	(Cycle I) Final Report Form and Instruction	New
196347	(Cycle II ) Final Report - end of grant Form and Instruction	Modified
196346	(Cycle II) Annual Report Form and Instruction	Modified
196345	(Cycle II) Transaction Data Collection Form and Instruction	Modified
196344	(Cycle II) Quarterly Report Form and Instruction	Modified
196343	(Cycle II) Application Form and Instruction	Modified
196342	(Cycle I) Application re-release Form and Instruction	Removed
196341	(Cycle I) Transaction Data Collection Form and Instruction	Modified
196340	(Cycle I) Quarterly Reports Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1121	ICR Reference No: 201107-0938-013
Status: Historical Active	Previous ICR Reference No: 201102-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Grants to States for Health Insurance Premium Review - Cycles I and II
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: 09/14/2011
	Date Received in OIRA: 07/26/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved	09/30/2011
Responses	1,075	0	964
Time Burden (Hours)	42,872	0	52,292
Cost Burden (Dollars)	0	0	0

---

Abstract: Cycle I Process The data collection is used by HHS to request that States and territories submit information for the Cycle I Health Insurance Premium Review Grants (quarterly reports, rate review transaction data, and a final Cycle I report) and Cycle II Health Insurance Premium Review Grants (application, quarterly reports, rate review transaction data, and a final Cycle II report). This information will assist HHS in planning for and executing grants to States for health insurance rate review.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1003 Name of Law: Ensuring that consumers get value for their dollars
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 28234	05/16/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44009	07/22/2011
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
(Cycle I) Quarterly Reports	CMS-10380	Cycle I - FOA
(Cycle I) Transaction Data Collection	CMS-10380	Cycle I FOA
(Cycle II) Application	CMS-10380	Cycle II - FOA
(Cycle II) Quarterly Report	CMA-10380	Cycle II FOA
(Cycle II) Transaction Data Collection	CMS-10380	Cycle II FOA
(Cycle II) Annual Report	CMS-10380	Cycle II FOA
(Cycle II ) Final Report - end of grant	CMS-10380	Cycle II FOA
(Cycle I) Final Report	CMS-10380	Cycle I FOA
(Cycle I) Application re-release	CMS-10380	CMS-10380.Deliberative Document

---

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	1,075	964	0	111	0	0
Annual Time Burden (Hours)	42,872	52,292	0	-9,420	0	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: The reason for the Program Changes or adjustments are due to the data collection needs for Cycle I grant awardees, including an update to the number of Cycle I applicants to correspond with the actual number of States and territories that applied and received grant awards and the associated burden for those 51 Cycle I participating States and territories in preparing and submitting quarterly reports and final reports. Similarly, we are revising the estimated burden for Cycle II applicants and potential grantees to correspond with the total possible number of applicants and their associated burden of applying, and preparing and submitting quarterly reports and final reports.

---

Annual Cost to Federal Government: $203,554

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

---

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: 07/26/2011

---