Model Employer Children's Health Insurance Program Notice

ICR 201308-1210-002

OMB: 1210-0137

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2013-09-30
Supporting Statement A
2013-08-27
ICR Details
1210-0137 201308-1210-002
Historical Active 201207-1210-001
DOL/EBSA
Model Employer Children's Health Insurance Program Notice
Extension without change of a currently approved collection   No
Regular
Approved without change 10/31/2013
Retrieve Notice of Action (NOA) 09/30/2013
  Inventory as of this Action Requested Previously Approved
10/31/2016 36 Months From Approved 10/31/2013
176,570,000 0 203,795,000
912,000 0 1,053,000
21,895,000 0 25,271,000

On February 4, 2009, President Obama signed the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA, Pub. L. 111-3). Under ERISA section 701(f)(3)(B)(i)(I), PHS Act section 2701(f)(3)(B)(i)(I), and section 9801(f)(3)(B)(i)(I) of the Internal Revenue Code, as added by CHIPRA, an employer that maintains a group health plan in a State that provides medical assistance under a State Medicaid plan under title XIX of the Social Security Act (SSA), or child health assistance under a State child health plan under title XXI of the SSA, in the form of premium assistance for the purchase of coverage under a group health plan, is required to make certain disclosures. Specifically, the employer is required to notify each employee of potential opportunities currently available in the State in which the employee resides for premium assistance under Medicaid and CHIP for health coverage of the employee or the employee's dependents. ERISA section 701(f)(3)(B)(i)(II) requires the Department of Labor to provide employers with model language for the Employer CHIP Notice to enable them to timely comply with this requirement. The model is required to include information on how an employee may contact the State in which the employee resides for additional information regarding potential opportunities for premium assistance, including how to apply for such assistance. Section 311(b)(1)(D) of CHIPRA provides that the Departments of Labor and Health and Human Services shall develop the initial Model Employer CHIP Notices under ERISA section 701(f)(3)(B)(i)(II), and the Department of Labor shall provide such notices to employers, by February 4, 2010. Moreover, each employer is required to provide the initial annual notices to such employer's employees beginning with the first plan year that begins after the date on which the initial model notices are first issued. The ICR relates to the Model Employer Chip Notice.

PL: Pub.L. 111 - 3 311(b)(1)(D) Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  
None

Not associated with rulemaking

  78 FR 30333 05/22/2013
78 FR 60897 10/02/2013
No

2
IC Title Form No. Form Name
Model Employer CHIP Notice (Private Sector Burden)
Model Employer CHIP Notice (State, Local, Tribal Governmental 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 176,570,000 203,795,000 0 0 -27,225,000 0
Annual Time Burden (Hours) 912,000 1,053,000 0 0 -141,000 0
Annual Cost Burden (Dollars) 21,895,000 25,271,000 0 0 -3,376,000 0
No
No
The agency has disaggregated burden. All other adjustments are due to changes in wage and employment rates, as well as changes in the states that choose whether or not to participate in the premium assistance program. In particular, California, which provided premium assistance at the time of the previous submission, no longer does so. This change in participation decreased the number of workers who might receive a CHIP Notice.

$0
No
No
No
No
No
Uncollected
Christopher Cosby 202-693-8425 [email protected]

  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.
09/30/2013


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