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)

Forms and Documents

Document Name	Status
CMS-10338_Supporting_Statement -30-day 51216.pdf Supporting Statement A	2016-06-20

IC Document Collections

IC ID	Document Title	Status
193861	Burden Estimates - Appeals Instruction	Modified

ICR Details

OMB Control No: 0938-1099	ICR Reference No: 201606-0938-004
Status: Historical Active	Previous ICR Reference No: 201503-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: 18839
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: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2016
	Date Received in OIRA: 07/01/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved	11/30/2016
Responses	399,154,868	0	218,000,000
Time Burden (Hours)	1,702,817	0	930,000
Cost Burden (Dollars)	115,714,242	0	52,000,000

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Abstract: The information collection requirements included in the claims procedure regulation ensure that participants and beneficiaries (claimants) receive adequate information regarding the plan's claims procedures and the plan's handling of specific benefit claims. Participants and beneficiaries need to understand plan procedures and plan decisions in order to appropriately request benefits and/or appeal benefit denials. The information collection requirements are necessary for the Federal external review process to provide an independent external review as requested by claimants.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2719 Name of Law: Appeals process
  

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:
	80 FR 72192	11/18/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 39644	06/17/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Burden Estimates - Appeals	CMS-10338, CMS-10338, CMS-10338	Adverse Benefit Determination Model Notice ,   Internal Adverse Benefit Determination ,   External Final Decision Model Notice

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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	399,154,868	218,000,000	0	0	181,154,868	0
Annual Time Burden (Hours)	1,702,817	930,000	0	0	772,817	0
Annual Cost Burden (Dollars)	115,714,242	52,000,000	0	0	63,714,242	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: One of the critical components of the original burden estimates was the number of plans expected to lose grandfathered status. These estimates have been updated based on more recent Medical Loss Ratio (MLR) data. There is nearly double the original estimate of non-grandfathered plans now subject to the Appeals regulation. 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 what state external review experience, such as data from the state of North Carolina. It is believed that this new rate is a more accurate reflection of the rate at which consumers request external reviews. Based on these adjustments, the estimated annual responses have increased from 218,657,161 to 399,154,868.

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Annual Cost to Federal Government: $168,015

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

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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: 07/01/2016

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