Model Employer Children's Health Insurance Program Notice

Forms and Documents

Document Name	Status
1210-0137 CHIPRA Model Notice 12-4-25.docx Supporting Statement A	2025-12-12

IC Document Collections

IC ID	Document Title	Status
208807	Model Employer CHIP Notice (State, Local, Tribal Governmental Burden) Other-Model Notice	Modified
191695	Model Employer CHIP Notice (Private Sector Burden) Other-Model Notice	Modified

ICR Details

OMB Control No: 1210-0137	ICR Reference No: 202508-1210-003
Status: Received in OIRA	Previous ICR Reference No: 202211-1210-002
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Model Employer Children's Health Insurance Program Notice
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/13/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2026
Responses	223,433,165	215,756,871
Time Burden (Hours)	776,430	751,554
Cost Burden (Dollars)	18,634,326	18,037,275

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Abstract: 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), Public Health Service Act (PHS) section 2701(f)(3)(B)(i)(I), and section 9801(f)(3)(B)(i)(I) of the Internal Revenue Code, as added by Children's Health Insurance Program Reauthorization Act of 2009 (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. These notices are referred to as “Employer CHIP Notices.” ERISA section 701(f)(3)(B)(i)(II) requires the Department of Labor to provide employers with model language for the Employer CHIP Notices to enable them to timely comply with this requirement, which is referred to as the “Model Employer CHIP Notice.” The model language 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.

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Authorizing Statute(s): PL: Pub.L. 111 - 3 311(b)(1)(D) Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  

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:
	90 FR 30984	07/11/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 1342	01/13/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Model Employer CHIP Notice (Private Sector Burden)
Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

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ICR Summary of Burden

	Total Request	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	223,433,165	215,756,871	0	0	7,676,294	0
Annual Time Burden (Hours)	776,430	751,554	0	0	24,876	0
Annual Cost Burden (Dollars)	18,634,326	18,037,275	0	0	597,051	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: The Department updated the employment rate data and the electronic disclosure rate. As a result, the number of responses has increased by 7,676,294 responses, the hour burden increased by 24,876 hours, and the cost burden has increased by $597,051.

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Annual Cost to Federal Government: $0

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]? No

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? No

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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: 01/13/2026

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