Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers (CMS-10338)

ICR 201606-0938-004

OMB: 0938-1099

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2016-06-20
IC Document Collections
IC ID
Document
Title
Status
193861 Modified
ICR Details
0938-1099 201606-0938-004
Historical Active 201503-0938-010
HHS/CMS 18839
Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers (CMS-10338)
Revision of a currently approved collection   No
Regular
Approved without change 11/21/2016
Retrieve Notice of Action (NOA) 07/01/2016
  Inventory as of this Action Requested Previously Approved
11/30/2019 36 Months From Approved 11/30/2016
399,154,868 0 218,000,000
1,702,817 0 930,000
115,714,242 0 52,000,000

The information collection requirements included in the claims procedure regulation ensure that participants and beneficiaries (claimants) receive adequate information regarding the plan's claims procedures and the plan's handling of specific benefit claims. Participants and beneficiaries need to understand plan procedures and plan decisions in order to appropriately request benefits and/or appeal benefit denials. The information collection requirements are necessary for the Federal external review process to provide an independent external review as requested by claimants.

PL: Pub.L. 111 - 148 2719 Name of Law: Appeals process
  
None

Not associated with rulemaking

  80 FR 72192 11/18/2015
81 FR 39644 06/17/2016
No

1
IC Title Form No. Form Name
Burden Estimates - Appeals CMS-10338, CMS-10338, CMS-10338 Adverse Benefit Determination Model Notice ,   Internal Adverse Benefit Determination ,   External Final Decision Model Notice

  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 399,154,868 218,000,000 0 0 181,154,868 0
Annual Time Burden (Hours) 1,702,817 930,000 0 0 772,817 0
Annual Cost Burden (Dollars) 115,714,242 52,000,000 0 0 63,714,242 0
No
No
One of the critical components of the original burden estimates was the number of plans expected to lose grandfathered status. These estimates have been updated based on more recent Medical Loss Ratio (MLR) data. There is nearly double the original estimate of non-grandfathered plans now subject to the Appeals regulation. Changes in the estimates for external review costs and the rate of external review requests also impacted the expected burden. The hour and cost burdens have been updated based on improved estimates of the costs associated with external review and the rate of external review. For example, the external review rate used to determine the expected number of external reviews was .03%. This rate was based on the Office of Personnel Management’s experience in operating the Federal Employee Health Benefit Plan (FEHBP). However, since OPM is no longer administering the HHS Federal External Review Program, we have updated our rate based on what state external review experience, such as data from the state of North Carolina. It is believed that this new rate is a more accurate reflection of the rate at which consumers request external reviews. Based on these adjustments, the estimated annual responses have increased from 218,657,161 to 399,154,868.

$168,015
No
No
Yes
No
No
Uncollected
Jamaa Hill 301 492-4190

  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.
07/01/2016


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