Calculation and Disclosure of Documentation of Eligibility for Exemption

ICR 200410-1210-002

OMB: 1210-0106

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1210-0106 200410-1210-002
Historical Active 200108-1210-001
DOL/EBSA
Calculation and Disclosure of Documentation of Eligibility for Exemption
Extension without change of a currently approved collection   No
Regular
Approved without change 12/20/2004
Retrieve Notice of Action (NOA) 10/29/2004
Approved without change for three years, as requested. OMB agrees that, should the authorizing legislation lapse, DOL shall submit form 83-D to discontinue this collection of information. OMB also notes that DOL plans to publish final rules for mental health parity after Congress has addressed the substance of the law, not simply extending it.
  Inventory as of this Action Requested Previously Approved
12/31/2007 12/31/2007 12/31/2004
200 0 200
10 0 10
0 0 0

The Mental Health Parity Act of 1996 requires parity between the dollar limits imposed on mental health benefits and those imposed on medical/surgical benefits offered by group health plans and issuers. Upon receipt of notice that a plan claims exemption from these requirements, participants and beneficiaries may request a summary of the information upon which the exemption was based. This ICR covers the calculation and disclosure of information on which the exemption was based.

None
None


No

1
IC Title Form No. Form Name
Calculation and Disclosure of Documentation of Eligibility for Exemption

  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 200 200 0 0 0 0
Annual Time Burden (Hours) 10 10 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
10/29/2004


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