Limited Wraparound Coverage Reporting (CMS-10571)

Forms and Documents

Document Name	Status
Form CMS-10571 Limited Wraparound Coverage Reporting Form and Instruction	New
CMS-10571 Appendix I Comment Response Summary 60-30day.docx Supplementary Document	2018-06-12
CMS-10571 Supporting Statement -Limited Wraparound Coverage Reporting.pdf Supporting Statement A	2018-04-04
CMS-10571 Appendix I Comment Response Summary.pdf Supplementary Document	2018-04-04
CMS-10571 - Appendix II Crosswalk Final.pdf Supplementary Document	2018-04-04

IC Document Collections

IC ID	Document Title	Status
230945	Limited Wraparound Coverage Reporting Form and Instruction	New

ICR Details

OMB Control No: 0938-1351	ICR Reference No: 201804-0938-002
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10571
Title: Limited Wraparound Coverage Reporting (CMS-10571)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/12/2018
	Date Received in OIRA: 04/17/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved
Responses	8	0	0
Time Burden (Hours)	24	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of Treasury, the Department of Labor and the Department of Health and Human Services published final regulations on March 18, 2015 (80 FR 13995), amending the regulations regarding excepted benefits under the Employee Retirement Income Security Act of 1974, the Internal Revenue Code, and the Public Health Service Act to specify requirements for limited wraparound coverage to qualify as an excepted benefit. The final regulations include requirements that limited wraparound coverage must satisfy in order to qualify as excepted benefits. One of them is a reporting requirement, for group health plans and group health insurance issuers, as well as group health plan sponsors. A self-insured group health plan, or a health insurance issuer offering or proposing to offer Multi-State Plan wraparound coverage, is required to report to OPM information reasonably required to determine whether the plan or issuer qualifies to offer such coverage or complies with the applicable requirements. In addition, the plan sponsor of any group health plan offering any type of limited wraparound coverage is required to report to the Department of Health and Human Services (HHS), in a form and manner specified in guidance by the Secretary of HHS.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2701-2763, 2791, 2792 Name of Law: Public Health Services Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2701-2763, 2791, 2792 Name of Law: Public Health Services Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 59622	12/15/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 13129	03/27/2018
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Limited Wraparound Coverage Reporting	CMS-10571	Wraparound Coverage Reporting Form

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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	8	0	8	0	0	0
Annual Time Burden (Hours)	24	0	24	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 request for information.

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Annual Cost to Federal Government: $727

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 04/17/2018

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