Establishing Creditable Coverage under Group Health Plans

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
HIPAA 1210-0103ss09.doc	Supporting Statement A	Uploaded 2009-11-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38420	Establishing Creditable Coverage under Group Health Plans		Modified

ICR Details

OMB Control No: 1210-0103	ICR Reference No: 200911-1210-003
Status: Historical Active	Previous ICR Reference No: 200609-1210-002
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Establishing Creditable Coverage under Group Health Plans
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 without change	Conclusion Date: 12/31/2009
	Date Received in OIRA: 12/01/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	12/31/2009
Responses	19,593,756	0	16,250,284
Time Burden (Hours)	88,066	0	75,306
Cost Burden (Dollars)	13,830,615	0	11,456,011

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Abstract: This ICR covers an information collection requirement imposed under the regulations in connection with the alternative method of crediting coverage established by the regulations. The regulations permit a plan to adopt, as its method of crediting prior health coverage, provisions that impose different preexisting condition exclusion periods with respect to different categories of benefits, depending on prior coverage in that category. In such a case, the regulations require former plans to provide additional information upon request to new plans in order to establish an individual’s length of prior creditable coverage within that category of benefits.

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Authorizing Statute(s): US Code: 29 USC 1181 Name of Law: Employee Retirement Income Security Act of 1974
  

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 49024	09/25/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 62828	12/01/2009
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
Establishing Creditable Coverage under Group Health Plans

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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	19,593,756	16,250,284	0	0	3,343,472	0
Annual Time Burden (Hours)	88,066	75,306	0	0	12,760	0
Annual Cost Burden (Dollars)	13,830,615	11,456,011	0	0	2,374,604	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: There have been no program changes to this ICR since the last submission in 2006. The Department has updated the estimates of respondents (plans) and responses, as well as the assumptions relating to cost (e.g., labor rates and worker characteristics). These changes have resulted in an increase in the numbers of responses, and a corresponding increase in the overall burden of this information collection.

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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)? No

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: 12/01/2009

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