FR 2025-07395

The document from the Department of Labor (DOL), published in the Federal Register, seeks public input on a proposed information collection concerning the procedures for internal claims and appeals, and external reviews under the Affordable Care Act. The Employee Benefits Security Administration (EBSA), part of the DOL, is overseeing this information collection request (ICR), which requires approval from the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995. Public comments are open until May 30, 2025, providing an opportunity for stakeholders to express their views and contribute to the policy-making process.

Summary of the Document

The purpose of this document is to invite comments from the public regarding the proposed information collection, which involves procedures for handling benefit claims and appeals in group health plans. This effort is part of implementing the Affordable Care Act, specifically section 2719 of the Public Health Service Act. The regulations aim to ensure that group health plans and health insurance issuers follow appropriate procedures for internal claims, appeals, and external review processes according to federal and state guidelines.

Significant Issues and Concerns

1. Complexity and Accessibility: The document references several complex legal and regulatory frameworks, such as the ERISA, the No Surprises Act, and various sections of the Public Health Service Act, without sufficient explanation. This complexity could hinder understanding among the general public and less-technical stakeholders, leading to potential difficulties in providing informed feedback.

2. Lack of Transparency: While the document mentions estimated annual time and cost burdens, it does not provide details on how these figures are calculated. This lack of transparency could raise questions about the accuracy of these estimates and diminish public trust in the process.

3. Navigation and Submission Process: The instructions for submitting comments are vague, particularly regarding how stakeholders can locate the correct information collection on the specified website. Clearer guidance would enhance participation and ensure that comments are submitted effectively.

4. Technical Language: The use of technical jargon, such as specific references to federal regulations, might be inaccessible to a non-specialist audience. Providing a glossary or simpler explanations would help broaden public engagement.

5. Assumptions of Prior Knowledge: Terms like "grandfathered plans" and "ERISA" are not commonly understood outside the field of employee benefits law. A lack of definitions for such terms may exclude some stakeholders from participating meaningfully in the comment process.

Impact on the Public and Stakeholders

Broad Public Impact:

This document impacts the broader public, specifically those involved in group health plans, by outlining how claims and appeals processes should be handled under federal law. The opportunity for public comment allows individuals and organizations to express concerns and suggestions, potentially influencing how these processes are implemented. The procedures aim to uphold transparency and fairness in claim handling, which ultimately benefits those covered by group health plans.

Impact on Specific Stakeholders:

• Private Sector and Businesses: For businesses and for-profit organizations, particularly those administering group health plans, these regulations establish a framework for compliance. While they increase transparency and fairness for beneficiaries, they may involve additional administrative efforts and costs, which are crucial for businesses to understand and plan for.

• Non-Profit Institutions: Similarly, non-profit organizations that offer group health insurance must also comply with these standards. Clarification of how the rules apply to them specifically would aid in effective implementation and minimize any unnecessary burdens.

In summary, while the document encourages public participation in refining claims and appeals processes under the Affordable Care Act, certain barriers such as complex language and lack of detailed guidance may hinder effective contribution from those it aims to serve. Addressing these issues could enhance the formulation of fair and effective health insurance practices.

The document from the Department of Labor (DOL) includes a reference to Total Estimated Annual Other Costs Burden: $613,741. This financial estimate relates to the costs associated with information collection requirements connected to the Affordable Care Act's internal claims and appeals and external review procedures for ERISA plans.

This cost burden is significant as it reflects the financial implications for entities required to comply with these regulatory requirements. However, the document does not disclose how this estimate was calculated, which raises questions about the transparency of the process. Entities affected by these financial burdens may seek clarity on what constitutes these costs, whether they include administrative expenses, technology upgrades, or other resources needed to meet compliance standards.

The document's presentation of the financial figures without detail may contribute to some of the identified issues. For example, understanding the calculation of this $613,741 could be vital for stakeholders who are concerned about the accuracy of such estimates. The absence of an explanation may make it challenging for businesses and other stakeholders to plan financially and provide meaningful comments to the OMB during the public comment period.

Given the complexity of the language used within the notice, this $613,741 figure might not be readily understood in context. Specific technical references and assumed prior knowledge further complicate stakeholders' ability to assess the practical implications of these costs on their operations. The issues noted suggest that there may be a need for clearer, more accessible communication regarding both the financial obligations implied by the regulations and the justification for the projected cost burdens.

By offering a more detailed breakdown or explanation of the $613,741 cost burden estimate, the document could help alleviate concerns around transparency and accuracy. This could, in turn, facilitate a more informed dialogue during the public comment phase, enabling stakeholders to engage more effectively with the regulatory process.