Opt-in State Balance Bill Process

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
1210-0168 State Opt-in Balance Bill Process 3-21-2025.docx	Supporting Statement A	Uploaded 2025-03-21	Repair queued
1210-0168 State Opt-in Balance Bill Process 3-21-2025.docx	Supporting Statement A	Uploaded 2025-03-21	Repair queued
No-Surprises-Act (1).pdf	Supplementary Document	Uploaded 2021-08-24	Available
No-Surprises-Act (1).pdf	Supplementary Document	Uploaded 2021-08-24	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248996	Opt-In State Balance Bill Process		Modified

ICR Details

OMB Control No: 1210-0168	ICR Reference No: 202411-1210-002
Status: Active	Previous ICR Reference No: 202202-1210-004
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Opt-in State Balance Bill Process
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/18/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/02/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved	07/31/2025
Responses	350	0	207
Time Burden (Hours)	525	0	311
Cost Burden (Dollars)	875	0	106

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Abstract: The No Surprises Act was enacted as part of the Consolidated Appropriations Act, 2021 (Pub. L. 116–260). The final rules allow plans to voluntarily opt in to state law that provides for a method for determining the cost-sharing amount or total amount payable under such a plan, where a state has chosen to expand access to such plans, to satisfy their obligations under section 9816(a)–(d) of the Code, section 716(a)–(d) of ERISA, and section 2799A–1(a)–(d) of the PHS Act. A plan that has chosen to opt into a state law must prominently display in its plan materials describing the coverage of outof-network services a statement that the plan has opted into a specified state law, identify the state (or states), and include a general description of the items and services provided by nonparticipating facilities and providers that are covered by the specified state aw.

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Authorizing Statute(s): PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56416	07/09/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 14482	04/02/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Opt-In State Balance Bill Process

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	350	207	0	0	143	0
Annual Time Burden (Hours)	525	311	0	0	214	0
Annual Cost Burden (Dollars)	875	106	0	0	769	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The estimates reflect the update in eight states that allow self-funded plans to opt in: New Jersey, Georgia, Maine, Washington, Virginia, and Nevada. The wage rates and the electronic disclosure rate have also been updated. As a result, the number of responses has increased by 143 responses, the hour burden has increased by 214 hours, and the cost burden has increased by $769.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/02/2025

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