Patient Protection and Affordable Care Act Patient Protection Notice

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
EBSA ACA Patient Protection ss15.docx	Supporting Statement A	Uploaded 2015-11-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193285	Patient Protection and Affordable Care Act Patient Protection Notice		Modified

ICR Details

OMB Control No: 1210-0142	ICR Reference No: 201510-1210-004
Status: Historical Active	Previous ICR Reference No: 201401-1210-003
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Patient Protection and Affordable Care Act Patient Protection Notice
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/04/2016
	Date Received in OIRA: 11/18/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	04/30/2017
Responses	693,007	0	1,700,000
Time Burden (Hours)	5,173	0	15,000
Cost Burden (Dollars)	5,371	0	13,000

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Abstract: The Patient Protection Notice is used by health plan sponsors and issuers to notify certain individuals of their right to (1) choose a primary care provider or a pediatrician when a plan or issuer requires participants or subscribers to designate a primary care physician; or (2) obtain obstetrical or gynecological care without prior authorization.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 10101(g) Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1210-AB72	Final or interim final rulemaking	80 FR 72192	11/18/2015

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 71668	11/29/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 11467	02/28/2014
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
Patient Protection and Affordable Care Act Patient Protection Notice

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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	693,007	1,700,000	0	0	-1,006,993	0
Annual Time Burden (Hours)	5,173	15,000	0	0	-9,827	0
Annual Cost Burden (Dollars)	5,371	13,000	0	0	-7,629	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 final rules do not change the information collections contained in the 2010 interim final regulations. The Department’s estimate had been updated to reflect a burden reduction due to the reduced number of impacted plans. Although this ICR may still impact plans in the future, the bulk of the burden associated occurred during the initial three year approval because this ICR only impacts plans that relinquish grandfathered status during the first year that they do so. As time goes on, most of the plans that intend to relinquish their grandfathered status will already have done so. The burden associated with continuing to provide this notice is factored into the estimates for the Summary Plan Description ICR (OMB Control Number 1210-0039).

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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]? 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: 11/18/2015

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