Patient Protection and Affordable Care Act Patient Protection Notice

ICR 202106-1210-002

OMB: 1210-0142

Federal Form Document

Forms and Documents
Supporting Statement A
Supplementary Document
IC Document Collections
ICR Details
1210-0142 202106-1210-002
Received in OIRA 201902-1210-004
Patient Protection and Affordable Care Act Patient Protection Notice
Revision of a currently approved collection   No
Regular 07/13/2021
  Requested Previously Approved
36 Months From Approved 05/31/2022
256,262 734,800
7,068 6,546
3,203 4,005

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.

PL: Pub.L. 111 - 148 10101(g) Name of Law: Affordable Care Act
PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

1210-AB99 Proposed rulemaking 86 FR 36872 07/13/2021


IC Title Form No. Form Name
Patient Protection and Affordable Care Act Patient Protection Notice

  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 256,262 734,800 -478,538 0 0 0
Annual Time Burden (Hours) 7,068 6,546 522 0 0 0
Annual Cost Burden (Dollars) 3,203 4,005 -802 0 0 0
The No Surprises Act added section 2799A-7 of the PHS Act, which contains the patient protections regarding choice of health care professional from section 2719A of the PHS Act. The patient protections under the No Surprises Act apply generally to all group health plans and health insurance coverage, including grandfathered health plans. The Department believes that only plans that relinquish their grandfathered status in 2021 and plans that are still grandfathered in 2022 will become subject to this notice requirement for the first time and incur the one-time costs to prepare the notice. Adjustments to the burden estimates also result from updated estimates on the number of plans and policyholders affected by the regulations, an increase in the share of notices assumed to be transmitted electronically, and increases in wage rates. These updated data inputs increase the hour burden by 522 hours compared with the prior submission and reduce the cost burden by $802 compared with the prior submission.

James Butikofer 202 693-8434 [email protected]


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.

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