PRA Form 14029 REG-120399-10 (2711 SS)

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
Section 2711 of the Public Health Service Act, incorporated into Code section 9815 by section 1563(f) of the Patient
Protection and Affordable Care Act, Public Law 111-148, requires group health plans and group health insurance
coverage to provide an individual whose coverage ended due to reaching a lifetime limit on the dollar value of all
benefits notice that the lifetime limit no longer applies and with an opportunity to enroll (including notice of an
opportunity to enroll) that continues for at least 30 days.

2. USE OF DATA
This is a third party disclosure requirement. Individuals who previously reached a lifetime limit may not know that plans
an dissuers cna no longer apply lifetime limits on the dollar value of all benefits or of the opportunity to enroll under
these regualtions unless the plan or health insurance issuer informs them. Individuals receiving the disclosure may
make an informed decision of whether they wish to enroll in the plan or health insurance coverage.

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.

4. EFFORTS TO IDENTIFY DUPLICATION
The regulations provide that the notice of enrollment opportunity may be provided with other plan enrollment materials,
provided that the notice of this enrollment opportunity is prominent. In addition, the regulations provide that 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
The regulations provide that 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 assume that the notice for all plans and policies (including self-insured plans that are administered
by insurers) will be prepared by the estimated 630 health insurers operating in the United States. On average, the
Departments expect that one-half hour of a legal professional’s time will be required to draft this notice, resulting in an
hour burden of approximately 160 hours. The Departments estimate that, on average, five minutes of a clerical staff
member’s time will be required to incorporate the specific information into the notice and mail the estimated 29,000
notices. This results in an estimated hour burden of approximately 2,400 hours. Therefore, the total hour burden of
this notice requirement is approximately 2,600 hours (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 estimate that the notice will be one-page in length, material and print costs will be five cents per
page, and postage will be 44 cents per notice resulting in a per notice cost of 49 cents. This leads to a total cost
burden of approximately $14,000 to distribute the notices (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