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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1099
ICR Reference No:
202110-0938-001
Status:
Historical Active
Previous ICR Reference No:
201911-0938-014
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CCIIO
Title:
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)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
10/07/2021
OIRA Conclusion Action:
Approved with change
Conclusion Date:
10/12/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/07/2021
Terms of Clearance:
Approved consistent with the understanding that the agency will review and consider all comments received from the rule in addition to those received during the 60 and 30 FRN periods as this package transitions from an emergency to a standard collection Previous terms also continue - upon submission of the standard collection, CMS should provide individual ICs detailing the various components of this collection
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2022
6 Months From Approved
05/31/2023
Responses
516,581,066
0
516,575,283
Time Burden (Hours)
1,198,692
0
1,195,626
Cost Burden (Dollars)
149,806,832
0
149,806,832
Abstract:
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.
Emergency Justfication:
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.
Authorizing Statute(s):
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
Citations for New Statutory Requirements:
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
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AU62
Final or interim final rulemaking
86 FR 55980
10/07/2021
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Burden Estimates - Appeals
Internal Claims and Appeals and External Review Procedures
ICR Summary 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
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
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 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.
Annual Cost to Federal Government:
$79,022
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]?
Yes
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
Agency Contact:
Jamaa Hill 301 492-4190
Common Form ICR:
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:
(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:
10/07/2021
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