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Federal forms, ICRs, and supporting documents

Information Collection Request

Recovery Act of 2009 - Request for Review If You Have Been Denied Premium Assistance

ICR 200909-0938-006 · OMB 0938-1062 · Historical Active

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Supplementary Document
2009-09-08
Supplementary Document
2009-09-08
Supplementary Document
2009-09-08
Supporting Statement A
2009-09-17
IC Document Collections
IC ID
Document
Title
Status
189030 Modified
ICR Details
0938-1062 200909-0938-006
Historical Active 200905-0938-001
HHS/CMS
Recovery Act of 2009 - Request for Review If You Have Been Denied Premium Assistance
Revision of a currently approved collection   No
Regular
Approved without change 11/06/2009
Retrieve Notice of Action (NOA) 09/17/2009
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved 11/30/2009
12,000 0 12,000
12,000 0 12,000
0 0 0
The American Recovery and Reinvestment Act of 2009 (P.L. 111-5) provides for premium assistance and expanded eligibility for health benefits under both the Consolidated Omnibus Budget Reconciliation Act of 1986, commonly called COBRA, and comparable state continuation coverage programs. This premium assistance is not paid directly to the covered employee or the qualified beneficiary, but instead is in the form of a tax credit for the health plan, the employer, or the insurer. "Assistance eligible individuals" pay only 35% of their continuation coverage premiums to the plan and the remaining 65% is paid through the tax credit. If an individual requests treatment as an assistance eligible individual and the employee's group health plan, employer, or insurer denies him or her the reduced premium assistance, the Secretary of Health and Human Services must provide for expedited review of the denial upon application to the Secretary in the form and manner the Secretary provides. The Secretary is required to make a determination within 15 business days after receipt of an individual's application for review. The Request for Review If You Have Been Denied Premium Assistance (the "Application") is the form that will be used by individuals to file their expedited review appeals. Each individual must complete all information requested on the Application in order for CMS to begin reviewing his or her case. An Application cannot be reviewed if sufficient information is not provided.
PL: Pub.L. 111 - 5 301(a)(5) Name of Law: Premium Assistance for Cobra Benefits
  
None
Not associated with rulemaking
  74 FR 30574 06/26/2009
74 FR 45861 09/04/2009
No
  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 12,000 12,000 0 0 0 0
Annual Time Burden (Hours) 12,000 12,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$2,300,000
No
No
Uncollected
Uncollected
Yes
Uncollected
Bonnie Harkless 4107865666
  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:
 
 
 
 
 
 
 
    (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.
09/17/2009