Affordable Care Act Internal
Claims and Appeals and External review Disclosures.
Revision of a currently approved collection
No
Emergency
03/18/2022
03/10/2022
Requested
Previously Approved
6 Months From Approved
07/31/2024
190,913
278,412
1,621
2,271
813,839
1,143,236
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.
The Department of
Labor’s Employee Benefit Security Administration (EBSA), in
conjunction with the Office of Personnel Management (OPM), the
Department of The Treasury, Internal Revenue Service (IRS), and the
Department of Health and Human Services (HHS), issued a joint
Interim Final Rule (IFR), Requirements Related to Surprise Billing;
Part II, which implements provisions of the No Surprises Act. The
No Surprises Act was enacted on December 27, 2020, as title I of
Division BB of the Consolidated Appropriations Act, 2021. The No
Surprises Act establishes new protections from surprise billing and
excessive cost-sharing for consumers receiving health care items
and services. Section 102 of the No Surprises Act contains
limitations on cost sharing and requirements for initial payments
for emergency services. Section 103 establishes a federal
independent dispute resolution (IDR) process that allows plans and
issuers and out-of-network providers to resolve disputes on
out-of-network rates. Section 105 contains limitations on cost
sharing and requirements for initial payments for air ambulance
services, and allows plans, issuers, and providers of air ambulance
services to access the federal IDR process. The IFR implements many
of the law’s requirements for group health plans, health insurance
issuers, carriers under the Federal Employees Health Benefits
(FEHB) Program, health care providers and facilities, and air
ambulance service providers. The requirements in the No Surprises
Act apply for plan years (in the individual market, policy years)
beginning on or after January 1, 2022. The Secretaries and OPM
Director have determined that it would be impracticable and
contrary to the public interest to delay putting the provisions in
these interim final rules in place until after a full public notice
and comment process has been completed. Although this effective
date may have allowed for the regulations, if promulgated with the
full notice and comment rulemaking process, to be applicable in
time for the applicability date of the provisions in the No
Surprises Act, this timeframe would not provide sufficient time for
the regulated entities to implement the requirements. It has been
determined that this information must also be collected prior to
the time periods established under Part 1320 of the Paperwork
Reduction Act (PRA) and that this information is essential to the
mission of EBSA to implement the provisions of the No Surprises
Act.
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 decrease the hour burden by 650 hours compared
with the prior submission and decrease the cost burden by $329,397
compared with the prior submission.
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.
Emergency Justification Memo 1545-2182_signed.pdf
1545-2182 SS_IFR2_AG.docx
Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review under the Patient Protection and Affordable Care Act