Notice of Pre-Existing Condition Exclusion Under ERISA

ICR 200412-1210-001

OMB: 1210-0102

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
38419
Migrated
ICR Details
1210-0102 200412-1210-001
Historical Active 200306-1210-008
DOL/EBSA
Notice of Pre-Existing Condition Exclusion Under ERISA
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 12/30/2004
Retrieve Notice of Action (NOA) 12/30/2004
  Inventory as of this Action Requested Previously Approved
10/31/2006 10/31/2006 10/31/2006
2,700,000 0 8,570,000
2,289 0 9,004
272,000 0 1,088,000

Under 29CFR 2590.701-3(c), a group health plan may not impose pre-existing exclusions on a participant unless the participant has been notified of the plan's provisions regarding the right to establish prior creditable coverage. Section 2590.701-5(d) requires that plans inform participants in writing of a determination to impose a pre-existing condition exclusion.

None
None


No

1
IC Title Form No. Form Name
Notice of Pre-Existing Condition Exclusion Under ERISA

  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 2,700,000 8,570,000 0 0 -5,870,000 0
Annual Time Burden (Hours) 2,289 9,004 0 0 -6,715 0
Annual Cost Burden (Dollars) 272,000 1,088,000 0 0 -816,000 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/30/2004


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