Coverage of Certain Preventive Services Under the Affordable Care Act

ICR 201306-1210-001

OMB: 1210-0150

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
205659
Modified
ICR Details
1210-0150 201306-1210-001
Historical Inactive 201302-1210-002
DOL/EBSA
Coverage of Certain Preventive Services Under the Affordable Care Act
New collection (Request for a new OMB Control Number)   No
Regular
Preapproved 08/28/2013
Retrieve Notice of Action (NOA) 06/28/2013
This information collection request is approved as submitted. However, DOL will evaluate the actual burden and number of respondents during this implementation period and will update the burden estimate accordingly via a nonsubstantive change request. Such update will occur no later than one year after this approval.
  Inventory as of this Action Requested Previously Approved
08/31/2016 36 Months From Approved
2 0 0
2 0 0
1 0 0

The Information Collection requires plans established or maintained by certain religious employers (and group health insurance coverage provided in connection with such plans) claiming exemption to providing contraceptive service to self-certify that it meets the definition of an eligible organization. The eligible organization would provide its health insurance issuer or third party administrator with a copy of its self-certification. The final regulations direct a third party administrator arranging or providing payments for contraceptive services at no cost to participants and beneficiaries in insured or self-insured plans (or student enrollees and covered dependents in student health insurance coverage) of eligible organizations to provide a written notice to such plan participants and beneficiaries (or such student enrollees and covered dependents) informing them of the availability of such payments. The notice must be provided contemporaneous with (to the extent possible) but separate from plan enrollment (or re-enrollment) materials, and must specify that contraceptive coverage will not be provided by the eligible organization but that the third party administrator will separately arrange or provide payments for contraceptive services, and must provide contact information for the third party administrator for questions and complaints. To satisfy the notice requirement, third party administrators may use the model language set forth in the final regulations or substantially similar language.

US Code: 29 USC 1185b Name of Law: Employee Retirement Income Security Act of 1974
  
None

1210-AB44 Final or interim final rulemaking

No

1
IC Title Form No. Form Name
Self-Certification EBSA Form 700

  Total Request 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 2 0 0 2 0 0
Annual Time Burden (Hours) 2 0 0 2 0 0
Annual Cost Burden (Dollars) 1 0 0 1 0 0
Yes
Changing Regulations
No
This is a new collection of information.

$0
No
No
Yes
No
No
Uncollected
Chris Cosby 202 693-8540

  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.
06/28/2013


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