Health Reimbursement Arrangements and Other Account-Based Group Health Plans

Forms and Documents

Document Name	Status
Form CMS-10704 Health Reimbursement Arrangements Form and Instruction	New
CMS-10704.Deliberative Document.docx Supporting Statement A	2019-06-10

IC Document Collections

IC ID	Document Title	Status
236410	Health Reimbursement Arrangements Form and Instruction	New

ICR Details

OMB Control No: 0938-1361	ICR Reference No: 201906-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Health Reimbursement Arrangements and Other Account-Based Group Health Plans
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 06/14/2019
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/11/2019
	Date Received in OIRA: 06/10/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	6 Months From Approved
Responses	272,680	0	0
Time Burden (Hours)	6,016	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collection requirements in the final rule is in response to Executive Order 13813, "Promoting Healthcare Choice and Competition Across the United States." It responds to comments on a proposal to adjust the usability of HRAs to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.

Emergency Justfication: We are requesting emergency approval for information collection requirements (ICRs) associated with rulemaking.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 2870 Name of Law: HIPAA nondiscrimination provisions
   PL: Pub.L. 111 - 148 2711 Name of Law: No lifetime or annual limits.
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2711 Name of Law: No lifetime or annual limits.
PL: Pub.L. 104 - 191 2870 Name of Law: HIPAA nondiscrimination provisions

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT90	Final or interim final rulemaking	83 FR 54420	10/29/2018

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Federal Register Notices & Comments

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
Health Reimbursement Arrangements	CMS-10704	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	272,680	0	272,680	0	0	0
Annual Time Burden (Hours)	6,016	0	6,016	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 information collection.

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Annual Cost to Federal Government:

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

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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: 06/10/2019

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