Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction

Forms and Documents

Document Name	Status
Form Form 301 Additional Information Request to Plan Administrator Form and Instruction	Modified
Form Form 300 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction Form and Instruction	Modified
Expedited_Review_of_Denial_of_Claims_ss12[1].docx Supporting Statement A	2012-10-01

IC Document Collections

IC ID	Document Title	Status
189162	Additional Information Request to Plan Administrator Form and Instruction	Modified
188224	Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction Form and Instruction	Modified

ICR Details

OMB Control No: 1210-0135	ICR Reference No: 201210-1210-002
Status: Historical Active	Previous ICR Reference No: 201004-1210-006
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/31/2013
	Date Received in OIRA: 11/27/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	184	0	15,400
Time Burden (Hours)	171	0	14,350
Cost Burden (Dollars)	104	0	8,000

---

Abstract: Section 3001 of the American Recovery and Reinvestment Act of 2009 (ARRA) provides "Assistance Eligible Individuals" with the right to pay reduced COBRA premiums for up to 9 months. If individuals request treatment as an assistance eligible individual and are denied such treatment because of their ineligibility for COBRA continuation coverage, ARRA section 3001(a)(5) requires the Secretary of Labor to provide for expedited review of the denial upon application to the Secretary in the form and manner the Secretary provides. The Secretary of Labor is required to act in consultation with the Secretary of the Treasury and must make a determination within 15 business days after receipt of an individual's application for review. The "Application to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction" (the "Application") is the form used by individuals to file their expedited review appeals. Such individuals must complete all information requested on the Application in order to file their review requests with the Department's Employee Benefits Security Administration (EBSA). The ICR relates to the Application.

---

Authorizing Statute(s): PL: Pub.L. 111 - 5 3001(a)(5) Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 37920	06/25/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 70827	11/27/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form 300	Application to U.S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Additional Information Request to Plan Administrator	Form 301	Plan Sponsor/Plan Administrator Information Sheet

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	184	15,400	0	0	-15,216	0
Annual Time Burden (Hours)	171	14,350	0	0	-14,179	0
Annual Cost Burden (Dollars)	104	8,000	0	0	-7,896	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The previous submission of this ICR reflected the Department's best efforts to estimate the hour and cost burden associated with it. The Department's current estimate is based on actual program usage data, which, as discussed in detail above, show a steady decline in the number of applications received by the Department. This has led to a reduction in the hour and cost burden estimate for this ICR.

---

Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/27/2012

---