Model Employer Children's Health Insurance Program Notice

ICR 201909-1210-008

OMB: 1210-0137

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2019-10-11
ICR Details
1210-0137 201909-1210-008
Active 201608-1210-001
DOL/EBSA
Model Employer Children's Health Insurance Program Notice
Extension without change of a currently approved collection   No
Regular
Approved with change 01/28/2020
Retrieve Notice of Action (NOA) 12/20/2019
  Inventory as of this Action Requested Previously Approved
01/31/2023 36 Months From Approved 01/31/2020
198,845,095 0 175,973,641
721,891 0 706,828
17,325,373 0 16,963,859

On February 4, 2009, President Obama signed the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA, Pub. L. 111-3). Under ERISA section 701(f)(3)(B)(i)(I), PHS Act section 2701(f)(3)(B)(i)(I), and section 9801(f)(3)(B)(i)(I) of the Internal Revenue Code, as added by CHIPRA, an employer that maintains a group health plan in a State that provides medical assistance under a State Medicaid plan under title XIX of the Social Security Act (SSA), or child health assistance under a State child health plan under title XXI of the SSA, in the form of premium assistance for the purchase of coverage under a group health plan, is required to make certain disclosures. Specifically, the employer is required to notify each employee of potential opportunities currently available in the State in which the employee resides for premium assistance under Medicaid and CHIP for health coverage of the employee or the employee's dependents. ERISA section 701(f)(3)(B)(i)(II) requires the Department of Labor to provide employers with model language for the Employer CHIP Notice to enable them to timely comply with this requirement. The model is required to include information on how an employee may contact the State in which the employee resides for additional information regarding potential opportunities for premium assistance, including how to apply for such assistance. Section 311(b)(1)(D) of CHIPRA provides that the Departments of Labor and Health and Human Services shall develop the initial Model Employer CHIP Notices under ERISA section 701(f)(3)(B)(i)(II), and the Department of Labor shall provide such notices to employers, by February 4, 2010. Moreover, each employer is required to provide the initial annual notices to such employer's employees beginning with the first plan year that begins after the date on which the initial model notices are first issued. The ICR relates to the Model Employer Chip Notice.

PL: Pub.L. 111 - 3 311(b)(1)(D) Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  
None

Not associated with rulemaking

  84 FR 11573 03/27/2019
84 FR 70212 12/20/2019
No

2
IC Title Form No. Form Name
Model Employer CHIP Notice (Private Sector Burden)
Model Employer CHIP Notice (State, Local, Tribal Governmental 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 198,845,095 175,973,641 0 0 22,871,454 0
Annual Time Burden (Hours) 721,891 706,828 0 0 15,063 0
Annual Cost Burden (Dollars) 17,325,373 16,963,859 0 0 361,514 0
No
No
There are no program changes for this submission. The burden estimates increased due to changes in employment rates, changes in the composition of the states that choose whether or not to participate in the program, and changes in the Department’s assumptions regarding the usage of electronic distribution.

$0
No
    No
    No
No
No
No
Uncollected
James Butikofer 202 693-8434 Butikofer.James@dol.gov

  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.
12/20/2019


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