Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EBSA Form 301 Additional Information Request to Plan Administrator	Form and Instruction	New	Available
Form EBSA Form 300 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form and Instruction	New	Available
COBRA - EBSA response to AHIP recommendations.rtf	Supplementary Document	Uploaded 2009-05-14	Available
COBRA Appeal Form Comment Letter (5-13-09).pdf	Supplementary Document	Uploaded 2009-05-14	Available
1210-0NEW- SS_COBRAPremiumAssistance.doc	Supporting Statement A	Uploaded 2009-05-15	Available
COBRAemergencyFRNappealfinal.doc	Supplementary Document	Uploaded 2009-04-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
189162	Additional Information Request to Plan Administrator	Form and Instruction	New
188224	Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form and Instruction	New

ICR Details

OMB Control No: 1210-0135	ICR Reference No: 200903-1210-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/15/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/20/2009
	Date Received in OIRA: 04/29/2009
Terms of Clearance: This is approved as an emergency collection. We look forward to working with the Department on ways to improve the practical utility of this form while reducing the burden. By the next submission, the Department will be prepared to describe how it uses all of the data collected to carry out program objectives.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2009	6 Months From Approved
Responses	104,500	0	0
Time Burden (Hours)	99,750	0	0
Cost Burden (Dollars)	52,000	0	0

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Abstract: Section 3001 of the American Recovery and Reinvestment Act of 2009 (ARRA) provides "Assistance Eligible Individuals" with the right to pay reduced COBRA premiums for up to 9 months. If individuals request treatment as an assistance eligible individual and are denied such treatment because of their ineligibility for COBRA continuation coverage, ARRA section 3001(a)(5) requires the Secretary of Labor to provide for expedited review of the denial upon application to the Secretary in the form and manner the Secretary provides. The Secretary of Labor is required to act in consultation with the Secretary of the Treasury and must make a determination within 15 business days after receipt of an individual’s application for review. The “Application to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction” (the "Application") is the form that will be used by individuals to file their expedited review appeals. Such individuals must complete all information requested on the Application in order to file their review requests with the Department’s Employee Benefits Security Administration (EBSA). The ICR relates to the Application.

Emergency Justfication: If the Department were to comply with standard PRA clearance procedures, it would not be able to implement its statutorily-mandated duty to provide for expedited review when individuals requests to be treated as assistance eligible individuals is denied by group help plans. As required by American Recovery and Reinvestment Act of 2009 (P.L. 111-5) section 3001(a)(5), the Department consulted with the Department of Health and Human Services in drafting the application for expedited review.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 3001(a)(5) Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 3001(a)(5) Name of Law: American Recovery and Reinvestment Act of 2009

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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:
	74 FR 20503	05/04/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	EBSA Form 300	Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Additional Information Request to Plan Administrator	EBSA Form 301	Request for Additonal Information from Plan Administrator

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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	104,500	0	104,500	0	0	0
Annual Time Burden (Hours)	99,750	0	99,750	0	0	0
Annual Cost Burden (Dollars)	52,000	0	52,000	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: New collection of information.

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Annual Cost to Federal Government: $6,858,000

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)? Yes

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: 04/29/2009

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