The CAA added provisions applicable to group health plans and health insurance issuers in the group and individual markets in a new Part D of title XXVII of the Public Health Service Act (PHS Act) and also added new provisions to part 7 of the Employee Retirement Income Security Act (ERISA), and Subchapter B of chapter 100 of the Internal Revenue Code (Code). Section 102 of the No Surprises Act added Code section 9816, ERISA section 716, and PHS Act section 2799A-1, which contain limitations on cost sharing and requirements for initial payments for emergency services. Section 103 of the No Surprises Act amended Code section 9816, ERISA section 716, and PHS Act section 2799A-1 to establish a Federal independent dispute resolution (Federal IDR) process that nonparticipating providers or facilities and group health plans and health insurance issuers in the group and individual market may use following the end of an unsuccessful open negotiation period to determine the out-of-network rate for certain services. More specifically, the Federal IDR provisions may be used to determine the out-of-network rate for certain emergency services, nonemergency items and services furnished by nonparticipating providers at participating health care facilities, where an All-Payer Model Agreement or specified state law does not apply. Section 105 of the No Surprises Act created Code section 9817, ERISA section 717, and PHS Act section 2799A-2 which contain limitations on cost sharing and requirements for initial payments for air ambulance services, and allow plans and issuers and providers of air ambulance services to access the Federal IDR process. CAA provisions that apply to health care providers and facilities, and providers of air ambulance services, such as requirements around cost sharing, prohibitions on balance billing for certain items and services, and requirements related to disclosures about balance billing protections, were added to title XXVII of the PHS Act in a new part E.
The Departments have updated the number of the IDR disputes that would be submitted annually as part of the Federal IDR process from 22,000 disputes to 420,000
disputes. Therefore, the hour burden has significantly increased.
In addition, the Departments have removed the hour burden for the additional information to be shared with the initial payment or notice of denial of payment, as this burden will now be included in HHS OMB Control Number 0938-1401. The Departments have also removed the following forms, as they will be included in the following HHS PRA package, "Patient Provider Dispute Resolution Requirements Related to Surprise Billing: Part II (CMS-10853)":
o Standard Form: âGood Faith Estimate for Health Care Items and Servicesâ Under the No Surprises Act.
o Standard Form: Patient-Provider Dispute Resolution (PPDR) Dispute Initiation Form.
o Standard Form: Online PPDR Initiation Form
o Standard Notice: Ineligible for PPDR or Additional Information Needed.
o Patient-Provider SDR Entity Certification Application Data Elements
o Independent Dispute Resolution and PPDR; Vendor Management Data Elements.
o PPDR Process Data Elements
o Standard Notice: SDR Determination Notice to Parties Provided Under the No Surprises Act.
o Standard Notice: SDR Entity Notification to Health Care Providers and Facilities and Uninsured (or Self-Pay) Individuals
o Standard Notice: Uninsured (or Self-Pay) Individual and Provider or Facility Settle on a Payment Amount After Initiating Patient Provider Dispute Resolution.
o Standard Notice: SDR Entity Notification to Health Care Provider or Facility and Uninsured (or Self-Pay) Individual Confirming Receipt of Dispute Settlement and Action.
o Standard Notice: Uninsured (or Self-Pay) Individual, Provider or Facilityâs Notification to Secretary of Health and Human Services
The Departments have also removed the form, âGood Faith Estimates Template Notice,â as the form has been included in HHS OMB Control Number 0938-1433.
Furthermore, the Departments have combined the hour and cost burden for nonparticipating providers or nonparticipating emergency Facilities and air ambulance providers, into one IC.
The Departments have also removed the cost burden for the requirement that certified IDR entities collect the administrative fee on behalf of the Departments, as the Departments propose to require each party participating in the Federal IDR process to pay the administrative fee directly to the Departments. The Departments have also added the hour burden for the registration of group health plans and health insurance issuers.
Finally, the Departments have updated the wage rates and postage costs. As a result, the number of responses has increased by 922,628 responses, the hour burden has increased by 1,481,469 hours, and the cost burden has increased by $10,592,979.
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.
Consolidated 1210-0169 Tri-dept PRA supporting statement 11.02.2023.docx
Registration of Group Health Plans and Health Insurance Issuers