MEDICAL NECESSITY DISCLOSURE UNDER MHPAEA AND CLAIMS DENIAL DISCLOSURE UNDER MHPAEA

Forms and Documents

Document	Type	Status	Availability
CMS-10307 Supporting Statement - Part A 30d 11-06-13.pdf	Supporting Statement A	Uploaded 2013-11-14	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
209346	Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Paper]		New
191609	Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Electronic]		Modified
191608	Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Paper]		Modified
191607	Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic]		Modified
191606	Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]		Modified
191605	Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]		Modified
191604	Medical Necessity Disclosure under MHPAEA [Processed In-House] [Paper]		Modified
191603	Medical Necessity Disclosure under MHPAEA [Processed In-House] [Electronic]		Modified
191602	Disclosure under MHPAEA [Processed By Issuer in the Individual Market]		Modified
191601	Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]		Modified
191600	Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]		Modified
191599	Claims Denial Disclosure under MHPAEA [Processed In-House] [Paper]		Modified
191598	Claims Denial Disclosure under MHPAEA [Processed In-House] [Electronic]		Modified

ICR Details

OMB Control No: 0938-1080	ICR Reference No: 201311-0938-020
Status: Historical Active	Previous ICR Reference No: 200912-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: 20948
Title: MEDICAL NECESSITY DISCLOSURE UNDER MHPAEA AND CLAIMS DENIAL DISCLOSURE UNDER MHPAEA
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/24/2014
	Date Received in OIRA: 11/14/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved
Responses	897,791	0	0
Time Burden (Hours)	27,983	0	0
Cost Burden (Dollars)	1,369,301	0	0

---

Abstract: Medical Necessity Disclosure under MHPAEA The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (P.L.110-343) requires that group health plans and group health insurance issuers offering mental health or substance use disorder (MH/SUD) benefits in addition to medical and surgical (med/surg) benefits ensure that that they do not apply any more restrictive financial requirements (e.g., co-pays, deductibles) and/or treatment limitations (e.g., visit limits) to MH/SUD benefits than those requirements and/or limitations applied to substantially all med/surg benefits.Medical Necessity Disclosure under MHPAEA section 512(b) specifically amends the Public Health Service (PHS) Act to require plan administrators or health insurance issuers to provide, upon request, the criteria for medical necessity determinations made with respect to MH/SUD benefits to current or potential participants, beneficiaries, or contracting providers. The Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (75 FR 5410, February 2, 2010) sets forth rules for providing criteria for medical necessity determinations. The final rules retain the provisions from the interim final rules and extend them to small employers and the individual market. CMS oversees non-Federal governmental plans or related health insurance and health insurance plans offered in the individual market.MHPAEA section 512(b) specifically amends the Public Health Service (PHS) Act to require plan administrators or health insurance issuers to supply, upon request, the reason for any denial of payment for MH/SUD services to the participant or beneficiary involved in the case.

---

Authorizing Statute(s): US Code: 42 USC 300gg-5(a)(4) Name of Law: Public Health Service Act section 2705
   PL: Pub.L. 110 - 343 512(b) Name of Law: Mental Health Parity and Addiction Equity Act of 2008
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 343 512(b) Name of Law: Mental Health Parity and Addiction Equity Act of 2008
US Code: 42 USC 300gg-5(a)(4) Name of Law: Public Health Service Act section 2705

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP65	Final or interim final rulemaking	78 FR 68239	11/13/2013

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 32661	05/31/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 68239	11/13/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 13

IC Title	Form No.	Form Name
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic]
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Paper]
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Electronic]
Claims Denial Disclosure under MHPAEA [Processed In-House] [Electronic]
Claims Denial Disclosure under MHPAEA [Processed In-House] [Paper]
Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]
Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]
Disclosure under MHPAEA [Processed By Issuer in the Individual Market]
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Electronic]
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Paper]
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Paper]

---

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	897,791	0	897,791	0	0	0
Annual Time Burden (Hours)	27,983	0	27,983	0	0	0
Annual Cost Burden (Dollars)	1,369,301	0	1,369,301	0	0	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 burden increased by approximately 25,782 hours and capital costs increased by approximately $198,964 because the disclosure requirements are extended to non-grandfathered insurance coverage in the small group market through the EHB requirements and to the individual markets, and due to an increase in mailing costs.

---

Annual Cost to Federal Government: $0

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)? No

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: 11/14/2013

---