Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
194345	External Review Process 2013	New
194344	External Review Process 2012	New
194343	External Review Process 2011	New
193862	Recordkeeping Requirements	Modified
193861	Disclosure for 2013	Modified
193860	Disclosure for 2012	Modified
193859	Disclosures for 2011	Modified

ICR Details

OMB Control No: 0938-1099	ICR Reference No: 201008-0938-015
Status: Historical Active	Previous ICR Reference No: 201008-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/23/2010
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/25/2010
	Date Received in OIRA: 08/20/2010
Terms of Clearance: CMS will update this record with the final version of the guidance and the model notices.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	6 Months From Approved	01/31/2011
Responses	211,213,878	0	211,213,350
Time Burden (Hours)	2,760,012	0	2,756,800
Cost Burden (Dollars)	109,200,000	0	109,200,000

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Abstract: The information collection requirements included in the claims procedure regulation ensure that participants and beneficiaries (claimants) receive adequate information regarding the plan's claims procedures and the plan's handling of specific benefit claims. Participants and beneficiaries need to understand plan procedures and plan decisions in order to appropriately request benefits and/or appeal benefit denials. The recordkeeping requirement will allow a participant, beneficiary, or Federal or state official to inspect important information regarding an issuers' internal claims and appeals processes and request and receive documents free of charge.

Emergency Justfication: The Patient Protection and Affordable Care Act (the "Affordable Care Act") was enacted by President Obama on March 23, 2010; the Health Care and Education Reconciliation Act (the "Reconciliation Act"), Pub. L. 111-152, was enacted on March 30, 2010. The Affordable Care Act and the Reconciliation Act reorganize, amend, and add to the provisions of part A of title XXVII of the Public Health Service Act (PHS Act) relating to group health plans and health insurance issuers in the group and individual markets. Section 2719 of the PHS Act sets forth standards for plans and issuers that are not grandfathered health plans regarding both internal claims and appeals and external review. The Departments of Labor, Health and Human Services, and the Treasury (the Departments) published interim final regulations implementing PHS Act section 2719 on July 23, 2010, at 75 FR 43330 ("the interim final regulations"). When the interim final regulations were issued OMB approved an information collection request (ICR) titled "Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Plans" under OMB Control Numbers 1210-0144 (Department of Labor), 1545-2182 (Internal Revenue Service, Department of the Treasury), and 0938-1099 (Department of Health and Human Services). The preamble to the interim final regulations provides that the Departments would be issuing additional guidance on the Federal external review process in the near future. The preamble states that the Departments also would issue model notices that could be used to satisfy the notice requirements under the interim final regulations. This action revises the ICRs under the OMB Control Numbers stated above to account for the hour and cost burden associated with the interim Federal external review process. The impact of the model notices, which also are being issued as part of this action, was accounted for in the ICR when the interim final regulations were issued. The Departments are requesting OMB to approve an emergency PRA submission, because they would not be able to publish the interim Federal external review guidance and model notices on a timely basis if the usual PRA processes were followed.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2719 Name of Law: Appeals process
  

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
	Other Documents for OIRA Review

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Disclosures for 2011
Disclosure for 2012
Disclosure for 2013
Recordkeeping Requirements
External Review Process 2011	CMS-10338
External Review Process 2012	CMS-10338
External Review Process 2013	CMS-10338

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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	211,213,878	211,213,350	0	528	0	0
Annual Time Burden (Hours)	2,760,012	2,756,800	0	3,212	0	0
Annual Cost Burden (Dollars)	109,200,000	109,200,000	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We are adding the model notices associated with the existing requirements. We are also adding the burden associated with the guidance for compliance with the requirements.

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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]? Yes

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: 08/20/2010

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