Coverage of Certain Preventive Services Under the Affordable Care Act

Forms and Documents

Document Name	Status
Form 700 IFR supporting statement 2-2015final.docx Supporting Statement A	2015-02-27
WheatonemergencyPRArequest.doc Supplementary Document	2014-08-07

IC Document Collections

IC ID	Document Title	Status
205659	Self-Certification or Notiffication Other-Model Notice	Modified

ICR Details

OMB Control No: 1210-0150	ICR Reference No: 201412-1210-002
Status: Historical Active	Previous ICR Reference No: 201408-1210-005
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Coverage of Certain Preventive Services Under the Affordable Care Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/14/2015
	Date Received in OIRA: 02/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2018	36 Months From Approved	04/30/2015
Responses	61	0	122
Time Burden (Hours)	51	0	51
Cost Burden (Dollars)	33	0	33

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Abstract: The Information Collection requires plans established or maintained by certain religious employers (and group health insurance coverage provided in connection with such plans) claiming exemption to providing contraceptive service to self-certify that it meets the definition of an eligible organization. The eligible organization would provide its health insurance issuer or third party administrator with a copy of its self-certification. The final regulations direct a third party administrator arranging or providing payments for contraceptive services at no cost to participants and beneficiaries in insured or self-insured plans (or student enrollees and covered dependents in student health insurance coverage) of eligible organizations to provide a written notice to such plan participants and beneficiaries (or such student enrollees and covered dependents) informing them of the availability of such payments. The notice must be provided contemporaneous with (to the extent possible) but separate from plan enrollment (or re-enrollment) materials, and must specify that contraceptive coverage will not be provided by the eligible organization but that the third party administrator will separately arrange or provide payments for contraceptive services, and must provide contact information for the third party administrator for questions and complaints. To satisfy the notice requirement, third party administrators may use the model language set forth in the final regulations or substantially similar language. The Departments issued interim final regulations in light of the Supreme Court's interim order in Wheaton College v. Burwell concerning notification to the Federal government that an eligible organization has a religious objection to providing contraceptive coverage, as an alternative to the EBSA Form 700, and to preserve participants' and beneficiaries' access to coverage for the full range of FDA-approved contraceptives, as prescribed by a health care provider, without cost sharing, which is also consistent with the Supreme Court's order. The interim final regulations amend the EBSA Form 700 ICR. The Department revised this ICR pursuant to the emergency PRA clearance procedures set forth under 5 CFR 1320.13 in order to implement the Supreme Court's order and make an alternative process for eligible organizations available as soon as possible. The Department is now requesting a full, three-year extension from OMB.

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Authorizing Statute(s): US Code: 29 USC 1185b Name of Law: Employee Retirement Income Security Act of 1974
  

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:
	79 FR 73629	12/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10719	02/27/2015
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Self-Certification or Notiffication	EBSA Form 700	Eligible Organization Self-Certification

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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	61	122	0	0	-61	0
Annual Time Burden (Hours)	51	51	0	0	0	0
Annual Cost Burden (Dollars)	33	33	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:

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Annual Cost to Federal Government:

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: 02/27/2015

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