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 301 Additional Information Request to Plan Administrator	Form and Instruction	Modified	Available
Form EBSA 301 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form	Modified	Repair queued
Justification for nonmaterial nonsubstantive change--COBRA Application.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2010-01-19	Available
1210-0135SSCOBRAexpeditedreviewfinal.doc	Supporting Statement A	Uploaded 2009-09-17	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 1210-0135	ICR Reference No: 201001-1210-003
Status: Historical Active	Previous ICR Reference No: 200909-1210-003
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/27/2010
	Date Received in OIRA: 01/20/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	11/30/2012	11/30/2012
Responses	15,400	0	15,400
Time Burden (Hours)	14,350	0	14,350
Cost Burden (Dollars)	8,000	0	8,000

---

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 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.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 28279	06/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 48780	09/24/2009
Did the Agency receive public comments on this ICR? Yes

---

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 301, EBSA 300	Plan Sponsor/Plan Administrator Information Sheet ,   Application to the U. S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Additional Information Request to Plan Administrator	EBSA 301	Plan Sponsor/Plan Administrator Information Sheet

---

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	15,400	15,400	0	0	0	0
Annual Time Burden (Hours)	14,350	14,350	0	0	0	0
Annual Cost Burden (Dollars)	8,000	8,000	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: The hour and cost burden associated with this ICR has been reduced since EBSA made its emergency submission in April 2009. This reduction is due to the fact that of eligible enrollees, EBSA has found that only .12 percent of the eligible population both applied for the COBRA subsidy, were denied, and formally appealed to the U.S. Department of Labor. The Department therefore estimates that only 14,000 individuals (reduced from 95,000) would file an appeal with the Department, and that the costs associated with the ICR would be $7,960 (reduced from $52,000).

---

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

---

Common Form ICR:  No

---

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: 01/20/2010

---