Recovery Act of 2009 - Request for Review If You Have Been Denied Premium Assistance

Forms and Documents

Document Name	Status
Form CMS-10285 Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance Form and Instruction	Modified
COBRA Resp OMB Terms Clrnc 5_29_09.doc Supplementary Document	2009-09-08
COBRA Crosswalk Changes 6 2_09.final.doc Supplementary Document	2009-09-08
COBRA mkd ICR _5_29_09.doc Supplementary Document	2009-09-08
COBRA SS_6_2_09_final.doc Supporting Statement A	2009-09-17

IC Document Collections

IC ID	Document Title	Status
189030	Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1062	ICR Reference No: 200909-0938-006
Status: Historical Active	Previous ICR Reference No: 200905-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Recovery Act of 2009 - Request for Review If You Have Been Denied Premium Assistance
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: 11/06/2009
	Date Received in OIRA: 09/17/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved	11/30/2009
Responses	12,000	0	12,000
Time Burden (Hours)	12,000	0	12,000
Cost Burden (Dollars)	0	0	0

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Abstract: The American Recovery and Reinvestment Act of 2009 (P.L. 111-5) provides for premium assistance and expanded eligibility for health benefits under both the Consolidated Omnibus Budget Reconciliation Act of 1986, commonly called COBRA, and comparable state continuation coverage programs. This premium assistance is not paid directly to the covered employee or the qualified beneficiary, but instead is in the form of a tax credit for the health plan, the employer, or the insurer. "Assistance eligible individuals" pay only 35% of their continuation coverage premiums to the plan and the remaining 65% is paid through the tax credit. If an individual requests treatment as an assistance eligible individual and the employee's group health plan, employer, or insurer denies him or her the reduced premium assistance, the Secretary of Health and Human Services must provide for expedited review of the denial upon application to the Secretary in the form and manner the Secretary provides. The Secretary is required to make a determination within 15 business days after receipt of an individual's application for review. The Request for Review If You Have Been Denied Premium Assistance (the "Application") is the form that will be used by individuals to file their expedited review appeals. Each individual must complete all information requested on the Application in order for CMS to begin reviewing his or her case. An Application cannot be reviewed if sufficient information is not provided.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 301(a)(5) Name of Law: Premium Assistance for Cobra Benefits
  

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:
	74 FR 30574	06/26/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 45861	09/04/2009
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
Recovery Act of 2009 - Request for Expedited Review of Denial of Premium Assistance	CMS-10285	Request for Review if you Have Been Denied Premium Assistance

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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	12,000	12,000	0	0	0	0
Annual Time Burden (Hours)	12,000	12,000	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: $2,300,000

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: 09/17/2009

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