Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10653 Model Notice to HHS	Form and Instruction	Modified	Available
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services	Form and Instruction	Modified	Available
Form CMS-10653 EBSA FORM 700 - Certification Form	Form and Instruction	Modified	Available
CMS-10653 Appendix I - Notice-Issuer-Third-Party-Employer-Preventive.pdf	Supplementary Document	Uploaded 2018-04-25	Available
CMS-10653 Summary of Changes 30-day.pdf	Supplementary Document	Uploaded 2018-04-25	Available
CMS-10653 Supporting Statement (2018 FR).docx	Supporting Statement A	Uploaded 2018-11-16	Available
CMS-10653 Appendix II Comment Response Summary 30d 4-11-18.pdf	Supplementary Document	Uploaded 2018-04-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
228593	Model Notice to HHS	Form and Instruction	Modified	Model Notice to HHS
228592	Notice of Availability of Separate Payments for Contraceptive Services	Form and Instruction	Modified	Notice of Availability of Separate Payments for Contraceptive Services
228591	Self-Certification & Notice to HHS	Form and Instruction	Modified	EBSA FORM 700 - Certification Form

ICR Details

OMB Control No: 0938-1344	ICR Reference No: 201804-0938-006
Status: Historical Active	Previous ICR Reference No: 201710-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/19/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/27/2018
Terms of Clearance: Upon approval, HHS will request to discontinue the control numbers 0938-1292 and 0938-1248.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved	11/30/2018
Responses	777,367	0	274,675
Time Burden (Hours)	181	0	181
Cost Burden (Dollars)	196,723	0	0

---

Abstract: Each organization seeking to be treated as an eligible organization that wishes to use the optional accommodation process offered under these final rules must either use the EBSA Form 700 method of self-certification or provide notice to HHS of its religious objection to coverage of all or a subset of contraceptive services.

---

Authorizing Statute(s): EO: EO 13798 Name/Subject of EO: Executive Order Promoting Free Speech and Religious Liberty
   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
   US Code: 42 USC 300gg-13 Name of Law: Coverage of preventive health services
   EO: EO 13765 Name/Subject of EO: Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pen
  

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
US Code: 42 USC 300gg-13 Name of Law: Coverage of preventive health services

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT54	Final or interim final rulemaking	83 FR 57536	11/15/2018

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 51843	11/08/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 17555	04/20/2018
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Model Notice to HHS	CMS-10653	Model Notice to HHS
Notice of Availability of Separate Payments for Contraceptive Services	CMS-10653	Notice of Availability of Separate Payments for Contraceptive Services
Self-Certification & Notice to HHS	CMS-10653	EBSA FORM 700 - Certification Form

---

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	777,367	274,675	0	502,692	0	0
Annual Time Burden (Hours)	181	181	0	0	0	0
Annual Cost Burden (Dollars)	196,723	0	0	196,723	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:

---

Annual Cost to Federal Government: $0

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

---

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: 04/27/2018

---