Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers
ICR 201009-0938-010
OMB: 0938-1099
Federal Form Document
⚠️ Notice: This information collection may be outdated.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
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
Departments of Labor issued additional guidance on the interim
federal external review process on August 23, 2010 and the
Department of Health and Human Services issued additional guidance
on this process on September 1, 2010. This action revises the ICRs
under the OMB Control Numbers stated above to account for the hour
and cost burden associated with clarifying that self-funded
non-federal governmental health plans that are not regulated by the
state are included in the interim Federal external review process.
In states with external review laws, these plans are required to
follow the Department of Labor Technical Guidance 2010-01. In
states without external review laws, these plans are required to
follow the interim federal external review process for health
insurance issuers in states without external review laws as
established in the technical guidance available at
http://www.hhs.gov/ociio/regulations/consumerappeals/interim_appeals_guidance.pdf.
The additional hour and cost burden associated with these new
requirements on self-funded non-federal governmental health plans
was calculated using the same assumptions in the original burden
estimates. HHS is requesting OMB to approve an emergency PRA
submission, because they would not be able to publish the interim
Federal external review guidance for self-funded non-federal
governmental health plans on a timely basis (by September 23rd) if
the usual PRA processes were followed.
We are revising the information
collection request to account for additional burden being imposed
on self-insured non-Federal plans.
$0
No
No
Yes
Uncollected
No
Uncollected
William Parham
4107864669
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.
States With External Review Laws - 2013