Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers
ICR 201008-0938-015 · OMB 0938-1099 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1099 can be found here:
Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers
CMS will update this record with the final version of the guidance and the model notices.
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
02/28/2011
6 Months From Approved
01/31/2011
211,213,878
0
211,213,350
2,760,012
0
2,756,800
109,200,000
0
109,200,000
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.
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.
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.
$0
No
No
Yes
Uncollected
No
Uncollected
William Parham 4107864669
Reginfo record details
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:
(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;
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.
External Review Process 2013