No Surprises Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
No Surprise Billing 1210-0NEW ss21 CLEAN 7.9.21.docx	Supporting Statement A	Uploaded 2021-07-13	Repair queued
No-Surprises-Act.pdf	Supplementary Document	Uploaded 2021-07-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248136	Plan and Issuer Disclosure on Patient Protections Against Balance Billing	Instruction	New
248135	Opt-In State Balance Bill Process		New
248134	Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities		New
247938	Complaints Process for Surprise Medical Bills		New

ICR Details

OMB Control No:	ICR Reference No: 202106-1210-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: No Surprises Act
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/13/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	10,368,277	0
Time Burden (Hours)	463,981	0
Cost Burden (Dollars)	279,496	0

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Abstract: The No Surprises Act: (1) directs the Department to establish a process to receive complaints regarding violations of the application of the qualifying payment amount by group health plans and health insurance issuers offering group coverage, and violations by health care provider, facilities, and providers of air ambulance services of the requirements under PHS Act sections 2799B-2 and 2799B-3. (2) require plans and issuers to provide certain information to nonparticipating providers or nonparticipating emergency facilities in cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider or nonparticipating emergency facility is the qualifying payment amount. (3) allow plans to voluntarily opt in to state law that provides for a method for determining the cost-sharing amount or total amount payable under such a plan, where a state has chosen to expand access to such plans, to satisfy their obligations under Code section 9816(a)-(d), ERISA section 716(a)-(d) and PHS Act section 2799A-1(a)-(d). (4) require plans and issuers to make publicly available, post on a public website of the plan or issuer, and include on each explanation of benefits for an item or service with respect to which the requirements under section 9816 of the Code, section 716 of ERISA, and section 2799A-1 of the PHS Act apply, information in plain language on the provisions in these sections, and sections 2799B-1 and 2799B-2 of the PHS Act, and other applicable state laws on out-of-network balance billing, and information on contacting appropriate state and federal agencies in the case that an individual believes that such a provider or facility has violated the prohibition against balance billing.

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Authorizing Statute(s): PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1210-AB99	Proposed rulemaking	86 FR 36872	07/13/2021

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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: 4

table that charts list of burden

IC Title	Form No.	Form Name
Complaints Process for Surprise Medical Bills
Opt-In State Balance Bill Process
Plan and Issuer Disclosure on Patient Protections Against Balance Billing
Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	10,368,277	0	10,368,277	0	0	0
Annual Time Burden (Hours)	463,981	0	463,981	0	0	0
Annual Cost Burden (Dollars)	279,496	0	279,496	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 collection of information.

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Annual Cost to Federal Government: $533,333

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]? No

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? No

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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: 07/13/2021

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