Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers (CMS-10338)

ICR 202110-0938-001

OMB: 0938-1099

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2021-10-07
Supporting Statement A
2021-10-05
IC Document Collections
ICR Details
0938-1099 202110-0938-001
Received in OIRA 201911-0938-014
HHS/CMS CCIIO
Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-grandfathered Group Health Plans and Issuers and Individual Market Issuers (CMS-10338)
Revision of a currently approved collection   No
Emergency 10/07/2021
10/07/2021
  Requested Previously Approved
6 Months From Approved 05/31/2023
516,581,066 516,575,283
1,198,692 1,195,626
149,806,832 149,806,832

These interim final regulations set forth rules implementing revisions to the Public Health Service (PHS) Act section 2719 for internal claims and appeals and external review processes to implement Section 110 of the No Surprises Act (NSA), which protects participants, beneficiaries, and enrollees in group health plans and group and individual health insurance coverage from receiving surprise medical bills when they receive emergency services, non-emergency services from non-participating providers at participating facilities, and air ambulance services, under certain circumstances. Specifically Section 110 of the NSA amends section 2719 of the PHS Act to require the external review process to apply to participants, beneficiaries, and enrollees of such plans with respect to any adverse determination by a plan or issuer under section 2799A-1 or 2799A-2 of the PHS Act. These protections also extend to grandfathered plans.
The surprise billing requirements for grandfathered plans as described under the September 2021 IFR apply for plan years beginning on or after January 1, 2022. If normal clearance procedures are followed, this statutory deadline may be missed and is likely to prevent the Departments from collecting information, such as data related to external review determinations for grandfathered plans.

US Code: 45 USC 147.136 Name of Law: Internal claims and appeals and external review processes
   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
US Code: 45 USC 147.136 Name of Law: Internal claims and appeals and external review processes

0938-AU62 Final or interim final rulemaking 86 FR 55980 10/07/2021

No

2
IC Title Form No. Form Name
Burden Estimates - Appeals
Internal Claims and Appeals and External Review Procedures

  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 516,581,066 516,575,283 5,783 0 0 0
Annual Time Burden (Hours) 1,198,692 1,195,626 3,066 0 0 0
Annual Cost Burden (Dollars) 149,806,832 149,806,832 0 0 0 0
No
No
The overall burden has increased from 1,195,626 hours to 1,198,692 hours, resulting in a total burden increase of 3,066 hours. The increase is mainly attributed to grandfathered plans required to meet external review standards for adverse benefit determinations subject to the surprise billing and cost-sharing protections. Changes in the estimates for external review costs and the rate of external review requests also impacted the expected burden. The hour and cost burdens have been updated based on improved estimates of the costs associated with external review, and the rate of external review. For example, the external review rate used to determine the expected number of external reviews was .03%. This rate was based on the Office of Personnel Management’s experience in operating the Federal Employee Health Benefit Plan (FEHBP). However, since OPM is no longer administering the HHS federal external review program, we have updated our rate based on data from states which conduct external reviews such as data from the state of North Carolina, which we believe provides a more accurate approximation of the rate at which consumers request external reviews. Based on these adjustments and external reviews for grandfathered plans, the estimated annual responses have increased from 516,575,283 to 516,581,066.

$79,022
No
    No
    No
Yes
No
No
No
Jamaa Hill 301 492-4190

  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.
10/07/2021


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