Affordable Care Act Internal Claims and Appeals and External Review Procedures for ERISA Plans

ICR 202108-1210-001

OMB: 1210-0144

Federal Form Document

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ICR Details
1210-0144 202108-1210-001
Received in OIRA 201902-1210-006
DOL/EBSA
Affordable Care Act Internal Claims and Appeals and External Review Procedures for ERISA Plans
Revision of a currently approved collection   No
Emergency 10/04/2021
10/01/2021
  Requested Previously Approved
6 Months From Approved 05/31/2022
190,913 329,980
1,621 2,816
813,839 1,381,946

This collection of information request includes the information collection and third party notice and disclosure requirements that a plan must satisfy under final regulations implementing provisions of the Affordable Care Act pertaining to internal claims and appeals, and the external review process. The No Surprise Act extends the balance billing protections related to external reviews to grandfathered plans. The definitions of group health plan and health insurance issuer that are cited in section 110 of the No Surprises Act include both grandfathered and non-grandfathered plans and coverage. Accordingly, the practical effect of section 110 of the No Surprises Act is that grandfathered health plans must provide external review for adverse benefit determinations involving benefits subject to these surprise billing protections. Grandfathered and non-grandfathered plans must provide claimants, free of charge, any new or additional evidence considered, relied upon, or generated by the plan or issuer in connection with the claim, and the requirement to comply either with a State external review process or a Federal review process. The disclosure requirements of the Federal external review process require (1) a preliminary review by plans of requests for external appeals; (2) Independent Review Organizations (IROs) to notify claimants of eligibility and acceptance for external review; (3) the plan or issuer to provide IROs with documentation and other information considered in making adverse benefit determination; (4) the IRO to forward to the plan or issuer any information submitted by the claimant; (5) plans to notify the claimant and IRO if it reverses its decision; (6) the IRO to notify the claimant and plan of the result of the final external appeal; 7) the IRO to maintain records for six years.
Before January 1, 2022, grandfathered health plans must provide external review for adverse benefit determinations involving benefits subject to these surprise billing protections. If normal clearance procedures are followed, this statutory deadline may be missed and the external review provisions will not be available with its accompany protections.

US Code: 42 USC 300gg-19 Name of Law: Public Health Service Act
   PL: Pub.L. 110 - 110 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021
  
PL: Pub.L. 110 - 110 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

1210-AC00 Final or interim final rulemaking

No

  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 190,913 329,980 -139,067 0 0 0
Annual Time Burden (Hours) 1,621 2,816 -1,195 0 0 0
Annual Cost Burden (Dollars) 813,839 1,381,946 -568,107 0 0 0
No
No
The No Surprise Act extends the balance billing protection related to external reviews to grandfathered plans. Under Section 110 of the No Surprises Act, grandfathered health plans must provide external review for adverse benefit determinations involving benefits subject to these surprise billing protections. Adjustments to the burden estimates result from updated estimates on the number of ERISA-covered plans and policyholders and increases in wage rates and postage rates. These updated data inputs increase the hour burden by 425 hours compared with the prior submission and increase the cost burden by $245,732 compared with the prior submission.

$0
No
    No
    No
Yes
No
No
No
James Butikofer 202 693-8434 [email protected]

  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.
10/01/2021


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