HIPAA Nondiscrimination Provisions

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10001 2009-02-11 Supporting Statement Version2.doc	Supporting Statement A	Uploaded 2009-03-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8623	HIPAA Nondiscrimination Provisions (CMS-10001)		Modified

ICR Details

OMB Control No: 0938-0827	ICR Reference No: 200901-0938-001
Status: Historical Active	Previous ICR Reference No: 200602-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: HIPAA Nondiscrimination Provisions
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 with change	Conclusion Date: 03/18/2009
	Date Received in OIRA: 01/05/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved	04/30/2009
Responses	18	0	18
Time Burden (Hours)	194	0	194
Cost Burden (Dollars)	0	0	0

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Abstract: This collection pertains to notices issued by self-funded non-Federal governmental plans to plan participants giving them an opportunity to enroll in a group health plan under certain circumstances, as required by 45 CFR section 146.121(i)(2)(i). The notices are triggered when coverage has been denied to any individual because the sponsor of a self-funded non-Federal governmental plan had elected under 146.180 to exempt the plan from the nondiscrimination requirements of this section, and the plan sponsor subsequently chooses to bring the plan into compliance with the requirements of this section. In that situation, the plan must notify the individual that the plan will be coming into compliance with the requirements of this section, afford the individual an opportunity to enroll that continues for at least 30 days, specify the effective date of compliance, and inform the individual regarding any enrollment restrictions that may apply under the terms of the plan once the plan is in compliance with this section (as a matter of administrative convenience, the notice may be disseminated to all employees).

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Authorizing Statute(s): US Code: 42 USC 300gg Name of Law: Section 2702(a) and (b) of the Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AI08	Final or interim final rulemaking	71 FR 75014	12/13/2006

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 57630	10/03/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 76032	12/15/2008
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
HIPAA Nondiscrimination Provisions (CMS-10001)

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ICR Summary of Burden

table that charts list 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	18	18	0	0	0	0
Annual Time Burden (Hours)	194	194	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: $0

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 01/05/2009

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