Supp. Stmnt. REG-120399-10 (T.D.9491)

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.

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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
The notice of this Interim Final Regulation was published in the Federal Register dated September 10, 2010 (75 FR
55402), to provide the public a 60-day period in which to review and provide public comments relating to any aspect of
this Interim Final Regulation. In response to the Federal Register notice, we received no comments during the
comment period regarding this Interim Final Regulation.

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, as the
regulations provide model language to 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), an average annual burden of $96,000 (50% to DOL and 50% to
IRS). Our notice dated September 10, 2010, (75 FR 55402), requested public comments, no responses were received

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

15. REASONS FOR CHANGE IN BURDEN
There were no changes made to the document that resulted in any change to the burden previously reported to OMB.
We are making this submission to renew the OMB approval.

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

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
We believe that displaying the OMB expiration date is inappropriate because it could cause confusion by leading
taxpayers to believe that the regulation sunsets as of the expiration date. Taxpayers are not likely to be aware that the
Service intends to request renewal of OMB approval and obtain a new expiration date before the old one expires.

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

19. REASON FOR EMERGENCY SUBMISSION
Not Applicable.

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

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Department of the Treasury–Internal Revenue Service