View Information Collection Request (ICR) Package
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Burden
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Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
0938-1344
ICR Reference No:
201804-0938-006
Status:
Historical Active
Previous ICR Reference No:
201710-0938-006
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/19/2018
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/27/2018
Terms of Clearance:
Upon approval, HHS will request to discontinue the control numbers 0938-1292 and 0938-1248.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2021
36 Months From Approved
11/30/2018
Responses
777,367
0
274,675
Time Burden (Hours)
181
0
181
Cost Burden (Dollars)
196,723
0
0
Abstract:
Each organization seeking to be treated as an eligible organization that wishes to use the optional accommodation process offered under these final rules must either use the EBSA Form 700 method of self-certification or provide notice to HHS of its religious objection to coverage of all or a subset of contraceptive services.
Authorizing Statute(s):
EO: EO 13798 Name/Subject of EO: Executive Order Promoting Free Speech and Religious Liberty
PL:
Pub.L. 111 - 148 1001
Name of Law: Amendments to the Public Health Service Act
PL:
Pub.L. 111 - 148 1563
Name of Law: Conforming amendments
US Code:
42 USC 300gg-13
Name of Law: Coverage of preventive health services
EO: EO 13765 Name/Subject of EO: Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pen
Citations for New Statutory Requirements:
PL: Pub.L. 111 - 148 1001 Name of Law: Amendments to the Public Health Service Act
PL: Pub.L. 111 - 148 1563 Name of Law: Conforming amendments
US Code: 42 USC 300gg-13 Name of Law: Coverage of preventive health services
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AT54
Final or interim final rulemaking
83 FR 57536
11/15/2018
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
82 FR 51843
11/08/2017
30-day Notice:
Federal Register Citation:
Citation Date:
83 FR 17555
04/20/2018
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
3
IC Title
Form No.
Form Name
Model Notice to HHS
CMS-10653
Model Notice to HHS
Notice of Availability of Separate Payments for Contraceptive Services
CMS-10653
Notice of Availability of Separate Payments for Contraceptive Services
Self-Certification & Notice to HHS
CMS-10653
EBSA FORM 700 - Certification Form
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
777,367
274,675
0
502,692
0
0
Annual Time Burden (Hours)
181
181
0
0
0
0
Annual Cost Burden (Dollars)
196,723
0
0
196,723
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:
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]?
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?
Uncollected
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:
04/27/2018
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