Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10459)

Forms and Documents

Document Name	Status
Form CMS-10459 Self-Certification Form and Instruction	New
Form CMS-10459 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction	New
CMS-10459 Supporting Statement FINAL .docx Supporting Statement A	2015-11-19

IC Document Collections

IC ID	Document Title	Status
218323	Self-Certification Form and Instruction	New
218321	Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction	New

ICR Details

OMB Control No: 0938-1292	ICR Reference No: 201509-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10459)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/24/2015
	Date Received in OIRA: 09/23/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	36 Months From Approved
Responses	149	0	0
Time Burden (Hours)	168	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The final rules titled "Coverage of Certain Preventive Services Under the Affordable Care Act" require each closely-held, for-profit corporation that has religious objection to coverage of all or a subset of contraceptive services and is seeking to be treated as an eligible organization to self-certify (using EBSA Form 700) that it meets the definition of an eligible organization. The eligible organization must provide a copy of its self-certification to a health insurance issuer that would otherwise provide such coverage in connection with the health plan for insured group health plans or student health insurance coverage, and to a third party administrator that would otherwise administer such coverage. Issuers and third party administrators providing or arranging payments for contraceptive services for participants and beneficiaries in plans of eligible organizations will be required to meet the notice requirements as set forth in the 2013 final regulations, requiring them to provide notice of the availability of separate payments for contraceptive services to participants and beneficiaries in the eligible organizations' plans (78 FR 39870, 39880 (July 2, 2013)). The final rules also permit an alternative process, consistent with the Wheaton order, under which an eligible organization may notify HHS of its religious objection to coverage of all or a subset of contraceptive services.

---

Authorizing Statute(s): 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: 45 USC 147.131(d) Name of Law: Exemption and accommodations in connection with coverage of preventive health services
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1001 Name of Law: Amendments to the Public Health Service Act

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51123	08/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 41317	07/14/2015
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Notice of Availability of Separate Payments for Contraceptive Services	CMS-10459	Notice of Availability of Separate Payments for Contraceptive Services
Self-Certification	CMS-10459	Self-Certification

---

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	149	0	149	0	0	0
Annual Time Burden (Hours)	168	0	168	0	0	0
Annual Cost Burden (Dollars)	0	0	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: This is a new collection of information.

---

Annual Cost to Federal Government: $0

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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

---

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: 09/23/2015

---