COBRA Crosswalk Changes 6 2_09

Crosswalk of Changes Between

Request for Expedited Review of Denial of Premium Assistance (4/09) and

Request for Review if You Have Been Denied Premium Assistance (6/09)

The table below outlines changes from the 4/09 information collection request (ICR). The vast majority of these changes fall within the clarification category. Except as noted, changes marked as clarification were made to keep the form as simple as possible by removing or using less technical language.

Section	Change(s)	Reason	Change in Reporting Burden
Introduction
Title	Changed from Request for Expedited Review of Denial of Premium Assistance to Request for Review if You Have Been Denied Premium Assistance.	Clarification	N/A
General Information	Removed technical language and discussion of the statute (i.e., payroll tax credits for employers).	Clarification	N/A
	Added simplified discussion 1. laying out rules to qualify for premium assistance; and 2. explaining types of employees whose group health insurance would allow them and their dependents to apply to CMS for review of denied premium assistance.	Clarification	N/A
	Updated contact information of contractor working for CMS on premium assistance project.	Clarification: update	N/A
Applying for Review	Advised individuals not sure of particular answers on how to fill out the form.	Clarification	N/A
Applying for Review	Corrected website and e-mail addresses of CMS’s contractor.	Clarification: corrections	N/A
Instructions
Title	Changed as per front page.	Clarification: correction	N/A
Number of Questions	Changed from “1-10” to “1-11.”	Clarification: correction	N/A
Question 6	Moved from Question 6 to 7 and reworded instructions sending employees of large private companies and their families to Department of Labor.	Clarification	N/A
Question 7	Removed technical instructions on counting part-time employees and special counting rules for multiemployer plans.	Clarification	N/A
Question 8	Slightly reworded last sentence to clarify that a State with comparable continuation coverage must take action for an additional election period to apply.	Clarification	N/A
Question 11	Changed if “exercised any delay or waiver” to “waived the right to collect.”	Clarification	N/A
Application
Title	Changed as per front page.	Clarification: correction	N/A
	Added OMB control number and expiration date.	Clarification	None
Applicant’s Information	Requested name of employee if applicant is not the employee.	Lessons learned	None
	Listed specific hours that applicant should provide the best phone number at which to be reached.	Clarification	None
	Removed requirement that applicant note whether his or her number(s) is for home, work or cell phone.	Clarification	None
Involuntary termination: Question 5, a - f	Added term “above” to indicate IRS guidance would help individuals fill out answer questions in 5.	Clarification	None
Information about employer; plan sponsor; parent company; and/or insurance, HMO or benefits administrator	Changed classification of entities that could possibly be involved in continuation coverage to create a new classification entitled “plan sponsor” for cases in which employers are not also plan sponsors.	Clarification	None
	For insurers category, requested phone and fax numbers, e-mail and website addresses, group number of insurance plan and applicant’s plan ID number. The request for this information was inadvertently left off the 4/09 ICR.	Clarification: correction	None
Signature Block	Specified that applicant is signing under the penalty of perjury.	Clarification	None
Paperwork Reduction Act Statement	Updated to reflect most current agency language.	Clarification	N/A

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information Unauthorized disclosure may result in prosecution to the full extent of the law

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