State Health Insurance Exchange Security Incident Report

Forms and Documents

Document Name	Status
Form CMS-10496 Incident Reporting Form and Instruction	Modified
CMS-10496.Supporting Statement Part A.pdf Supporting Statement A	2014-03-06

IC Document Collections

IC ID	Document Title	Status
208397	Incident Reporting Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1216	ICR Reference No: 201403-0938-002
Status: Historical Active	Previous ICR Reference No: 201308-0938-026
Agency/Subagency: HHS/CMS	Agency Tracking No: 21546
Title: State Health Insurance Exchange Security Incident Report
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: 04/21/2014
	Date Received in OIRA: 03/06/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	04/30/2014
Responses	936	0	936
Time Burden (Hours)	234	0	234
Cost Burden (Dollars)	0	0	0

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Abstract: As part of the privacy and security oversight of State Health Insurance Exchanges the States will be required to report security incidents include breaches of personally identifiable information (PII). This reporting will be made by completing and electronically submitting the State Health Insurance Exchange Security Incident Report (Incident Report), or providing identical information telephonically.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 Title1 Name of Law: Affordable Care Act
  

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 77135	12/20/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 11435	02/28/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Incident Reporting	CMS-10496	STATE HEALTH INSURANCE EXCHANGE SECURITY INCIDENT REPORT

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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	936	936	0	0	0	0
Annual Time Burden (Hours)	234	234	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: $502

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: 03/06/2014

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