PRA Form 14029 REG-120399-10 (2719A SS)

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
Section 2719A of the Public Health Service Act (PHS Act), incorporated into Code section 9815 by section 1563(f) of
the Patient Protection and Affordable Care Act, Public Law 111-148, requires that a group health plan or a health
insurance issuer requiring or allowing for the designation of a primary care provider provide notice to participants of the
right to designate a primary care provider (including a pediatrician for a child) and of the right to obtain access to
obstetrical or gynecological services without referral from a primary care provider.

2. USE OF DATA
This is a third party disclosure requirement. Individuals who are required to designate a primary care provider need to
know about their rights under PHS Act section 2719A to designate any available primary care provider in the plan's
network, to designate a pediatrician as the primary care provider for a child, and to receive obstetricla or gynecological
services without the referral of a primary care provider.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
Plans and issuers may satisfy this disclosure requirement by electronic means if they comply with applicable electronic
disclosure requirements. The Departments estimate that 38% of the notices will be furnised electronically.

4. EFFORTS TO IDENTIFY DUPLICATION
Under the regulations, this notice of patient protections must be provided at the time that descriptions of plan benefits
are distributed; it is expected that this notice will be provided as part of that distribution. In addition, under the
regulations, the provision of the notice by either the plan or the issuer satisfies the obligation for both parties.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
Under the regulations, a single notice provided to an individual will satisfy the obligation for both parties responsible for
providing the notice, the plan and the issuer. Most small businesses maintaining a group health plan provide benefits
through health insurance coverage. In such a case, it is expected that the issuer of the health insurance coverage will
satisfy the notice obligation on behalf of both the plan and the issuer.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Not applicable -- collection is one-time.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
Not applicable.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
Comments are requested in the temporary regulations.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
Not applicable.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
Not applicable.

11. JUSTIFICATION OF SENSITIVE QUESTIONS
Not applicable.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
The Departments estimate that 339,000 ERISA-covered plans will need to notify an estimated 8.0 million policy holders
of their plans’ policy in regards to designating a primary care physician and for obstetrical or gynecological visits.
Because the interim final regulations provide model language for this purpose, the Departments estimate that five
minutes of clerical time will be required to incorporate the required language into the plan document and ten minutes of
a human resource professional’s time will be required to review the modified language. These burdens will vary from
year to year. Therefore, the Departments estimate that plans will incur an average annual hour burden of 66,000
hours to meet the disclosure requirement (50% to DOL and 50% to IRS).

Form 14029 (Rev. 4-2009) Catalog Number 51944B

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Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
The Departments assume that only printing and material costs are associated with the disclosure requirement,
because the regulations provide model language that can be incorporated into existing plan documents. The
Departments estimate that the notice will require one-half of a page, five cents per page printing and material cost will
be incurred, and 38 percent of the notices will be delivered electronically. This results in a cost burden for the first year
of $124,000 ($0.05 per page*1/2 pages per notice * 8.0 million notices*0.62), but an average annual burden of $96,000
(50% to DOL and 50% to IRS).

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
Not applicable -- third party disclosure.

15. REASONS FOR CHANGE IN BURDEN
New ICR.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
Not applicable.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
Not applicable.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
Not applicable.

19. REASON FOR EMERGENCY SUBMISSION
New statute with imminent applicability.

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 6

Department of the Treasury–Internal Revenue Service