Employer Notification Request to HHS of its Objection to Providing Contraceptive Services (CMS-10535)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CM-10535_IFR Emergency Justification (8-19-14).docx	Supplementary Document	Uploaded 2014-08-21	Available
CMS-10535_IFR supporting_statement_8_19_14.pdf	Supporting Statement A	Uploaded 2014-08-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212753	Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification		New

ICR Details

OMB Control No: 0938-1248	ICR Reference No: 201411-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Employer Notification Request to HHS of its Objection to Providing Contraceptive Services (CMS-10535)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/05/2014
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/11/2014
	Date Received in OIRA: 11/04/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	6 Months From Approved
Responses	122	0	0
Time Burden (Hours)	110	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The interim final regulations titled "Coverage of Certain Preventive Services Under the Affordable Care Act" continue to allow such eligible organizations to notify an issuer or third party administrator using EBSA Form 700, as set forth in the July 2013 final regulations. In addition, the interim final regulations permit an alternative process, consistent with the Wheaton order, under which an eligible organization could notify the Secretary of HHS that it will not act as the plan administrator or claims administrator with respect to, or contribute to the funding of, coverage of all or a subset of contraceptive services.

Emergency Justfication: Please see attached emergency justification.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1563 Name of Law: Conforming Amendments
   US Code: 42 USC 300gg-13 Name of Law: Coverage of preventive health services
   PL: Pub.L. 111 - 148 1001 Name of Law: Amendments to the Public Health Service Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1001 Name of Law: Amendments to the Public Health Service Act
PL: Pub.L. 111 - 148 1563 Name of Law: Conforming amendments

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS49	Final or interim final rulemaking	79 FR 51092	08/27/2014

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification

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ICR Summary of Burden

table that charts list 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	122	0	122	0	0	0
Annual Time Burden (Hours)	110	0	110	0	0	0
Annual Cost Burden (Dollars)	0	0	0	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: This is a new information collection request.

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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]? Yes

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

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Common Form ICR:  No

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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: 11/04/2014

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