DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
Center for Medicaid & State Operations 
 
CMSO Informational Bulletin 
  
 
DATE:            March 2, 2010 
 
TO:  Childrens Health Insurance Officials 
  State Medicaid Directors 
 
CC:   CMSO Staff 
  Medicaid Associate Regional Administrators 
   
FROM:  Cindy Mann, Director 
  Center for Medicaid and State Operations (CMSO) 
 
SUBJECT:  Publication of Model Notice for Employers to use Regarding Premium Assistance 
under Medicaid or the Childrens Health Insurance Program 
 
STATUTE:  Section 311(b)(1)(D) of CHIPRA provides that the Departments of Labor (DOL) 
and Health and Human Services shall develop initial model notices as provided 
under ERISA section 701(f)(3)(B)(i)(II) and the DOL shall provide such notices 
to employers by February 4, 2010; one year after the enactment of CHIPRA.  
 
CMSO CONTACT: Stacey Green, 410-786-6102, stacey.green@cms.hhs.gov 
 
As you are aware, the Childrens Health Insurance Program Reauthorization Act of 2009 
(CHIPRA, Pub. L. 1113) includes a requirement that the Departments of Labor and Health and 
Human Services develop a model notice for employers to use to inform employees of potential 
opportunities currently available in the State for premium assistance under Medicaid and the 
Childrens Health Insurance Program (CHIP). The Department of Labor is required to provide 
the model notice to employers within one year of CHIPRAs enactment.  
 
On February 4, 2010, the Department of Labor announced the availability of a model employer 
Medicaid and CHIP notice in the Federal Register.  Attached are copies of the model employer 
Medicaid and CHIP notice, and the Federal Register announcement. This Federal Register 
announcement also requests comments regarding compliance with the model employer notice 
requirement for use in the development of future compliance assistance materials and/or 
regulations.  
 
There is no obligation for States to take any action relative to the model employer Medicaid and 
CHIP notice.  However, we do encourage States to view the Federal Register notice and make 
comments as appropriate.  Comments on the Federal Register notice are due on or before  
April 5, 2010 and must be submitted in accordance with the Federal Register instructions.  
Please contact Stacey Green if you have any additional questions.    
  Attachments 
   
Medicaid and the Childrens Health Insurance Program (CHIP)  
Offer Free Or Low-Cost Health Coverage To Children And Families 
 
If you are eligible for health coverage from your employer, but are unable to afford the premiums, 
some States have premium assistance programs that can help pay for coverage.  These States use 
funds from their Medicaid or CHIP programs to help people who are eligible for employer-
sponsored health coverage, but need assistance in paying their health premiums.  
   
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed 
below, you can contact your State Medicaid or CHIP office to find out if premium assistance is 
available.   
 
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or 
any of your dependents might be eligible for either of these programs, you can contact your State 
Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to 
apply.  If you qualify, you can ask the State if it has a program that might help you pay the 
premiums for an employer-sponsored plan.   
 
Once it is determined that you or your dependents are eligible for premium assistance under 
Medicaid or CHIP, your employers health plan is required to permit you and your dependents to 
enroll in the plan  as long as you and your dependents are eligible, but not already enrolled in the 
employers plan.  This is called a special enrollment opportunity, and you must request 
coverage within 60 days of being determined eligible for premium assistance.   
 
 
 
If you live in one of the following States, you may be eligible for assistance paying your 
employer health plan premiums.  The following list of States is current as of January 22, 2010.  
You should contact your State for further information on eligibility  
 
 
ALABAMA  Medicaid  CALIFORNIA  Medicaid 
   
Website: http://www.medicaid.alabama.gov  Website: http://www.dhcs.ca.gov/ Pages/ 
  default.aspx 
Phone: 1-800-362-1504 
 
  Phone: 1-800-635-2570 
ALASKA  Medicaid  COLORADO  Medicaid and CHIP 
   
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ 
Medicaid Website: http://www.colorado.gov/ 
 
Phone (Outside of Anchorage): 1-888-318-8890   
Medicaid Phone: 1-800-866-3513 
 
Phone (Anchorage): 907-269-6529   
CHIP Website: http:// www.CHPplus.org 
 
ARIZONA  CHIP   
CHIP Phone: 303-866-3243
   
Website: http://www.azahcccs.gov/applicants/default.aspx 
 
Phone: 602-417-5422 
 
ARKANSAS  CHIP   FLORIDA  Medicaid 
   
Website: http://www.arkidsfirst.com/  Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml 
   
Phone: 1-888-474-8275  Phone: 1-866-762-2237 
  GEORGIA  Medicaid  MONTANA  Medicaid 
   
Website: http://dch.georgia.gov/   Website: http://medicaidprovider.hhs.mt.gov/clientpages/ 
  clientindex.shtml 
    Click on Programs, then Medicaid 
 
  Telephone: 1-800-694-3084 
Phone: 1-800-869-1150 
 
 
IDAHO  Medicaid and CHIP  NEBRASKA  Medicaid 
   
Medicaid Website: www.accesstohealthinsurance.idaho.gov  Website: http://www.dhhs.ne.gov/med/medindex.htm 
   
Medicaid Phone: 208-334-5747  Phone: 1-877-255-3092 
   
CHIP Website: www.medicaid.idaho.gov   
 
CHIP Phone: 1-800-926-2588
 
INDIANA  Medicaid  NEVADA  Medicaid and CHIP 
   
Website: http://www.in.gov/fssa/2408.htm  Medicaid Website:  http://dwss.nv.gov/ 
   
Phone: 1-877-438-4479  Medicaid Phone:  1-800-992-0900 
   
IOWA  Medicaid  CHIP Website: http://www.nevadacheckup.nv.org/ 
 
  CHIP Phone: 1-877-543-7669 
Website: www.dhs.state.ia.us/hipp/ 
 
   
Phone: 1-888-346-9562 
 
 
KANSAS  Medicaid  NEW HAMPSHIRE  Medicaid 
   
Website: https://www.khpa.ks.gov  Website: http://www.dhhs.state.nh.us/DHHS/ 
  MEDICAIDPROGRAM/default.htm 
Phone: 1-800-635-2570 
 
  Phone: 1-800-852-3345 x 5254
 
KENTUCKY  Medicaid  NEW JERSEY  Medicaid and CHIP 
   
Website: http://chfs.ky.gov/dms/default.htm  Medicaid Website: http://www.state.nj.us/humanservices/ 
  dmahs/clients/medicaid/ 
Phone: 1-800-635-2570 
 
  Medicaid Phone: 1-800-356-1561 
LOUISIANA  Medicaid 
 
  CHIP Website: http://www.njfamilycare.org/index.html 
Website: www.dhh.louisiana.gov/offices/?ID=92   
  CHIP Phone: 1-800-701-0710 
Phone: 1-888-342-0555   
MAINE  Medicaid  NEW MEXICO  Medicaid and CHIP 
   
Website: http://www.maine.gov/dhhs/oms/  Medicaid Website: 
  http://www.hsd.state.nm.us/mad/index.html 
Phone: 1-800-321-5557 
 
  Medicaid Phone: 1-888-997-2583 
MASSACHUSETTS  Medicaid and CHIP 
 
  CHIP Website:  
Medicaid & CHIP Website: 
http://www.hsd.state.nm.us/mad/index.html 
http://www.mass.gov/MassHealth 
      Click on Insure New Mexico 
 
Medicaid & CHIP Phone: 1-800-462-1120   CHIP Phone: 1-888-997-2583 
 
   
MINNESOTA  Medicaid  NEW YORK  Medicaid 
   
Website: http://www.dhs.state.mn.us/  Website: http://www.nyhealth.gov/health_care/ 
  medicaid/ 
    Click on Health Care, then Medical Assistance 
 
  Phone: 1-800-541-2831 
Phone: 800-657-3739 
 
 
MISSOURI  Medicaid  NORTH CAROLINA  Medicaid 
   
Website: http://www.dss.mo.gov/mhd/index.htm  Website:  http://www.nc.gov 
   
Phone: 573-751-6944  Phone:  919-855-4100 
   
 
    NORTH DAKOTA  Medicaid  UTAH  Medicaid 
   
Website:  Website: http://health.utah.gov/medicaid/ 
http://www.nd.gov/dhs/services/medicalserv/medicaid/   
Phone: 1-866-435-7414 
 
Phone: 1-800-755-2604   
 
OKLAHOMA  Medicaid  VERMONT Medicaid 
   
Website: http://www.insureoklahoma.org  Website: http://ovha.vermont.gov/ 
   
Phone: 1-888-365-3742  Telephone: 1-800-250-8427 
   
OREGON  Medicaid and CHIP  VIRGINIA  Medicaid and CHIP
 
   
Medicaid Website:  Medicaid Website:  http://www.famis.org/ 
http://www.oregon.gov/DHS/healthplan/index.shtml   
Medicaid Phone:  1-800-432-5924 
 
Medicaid Phone: 1-800-359-9517   CHIP Website: http://www.famis.org/ 
 
CHIP Website:   CHIP Phone: 1-866-873-2647 
http://www.oregon.gov/DHS/healthplan/app_benefits/ 
 
ohp4u.shtml 
 
CHIP Phone: 1-800-359-9517 
 
PENNSYLVANIA  Medicaid  WASHINGTON  Medicaid 
   
Website:   
Website:  http://ihrsa/sites/DCS/COB/default.aspx 
http://www.dpw.state.pa.us/partnersproviders/medicalassista
 
nce/doingbusiness/003670053.htm  Phone:  1-800-562-6136 
   
Phone: 1-800-644-7730 
 
RHODE ISLAND  Medicaid  WEST VIRGINIA  Medicaid 
   
Website: www.dhs.ri.gov  Website:  http://www.wvrecovery.com/hipp.htm 
   
Phone: 401-462-5300  Phone:  304-342-1604 
   
SOUTH CAROLINA  Medicaid  WISCONSIN  Medicaid 
   
Website: http://www.scdhhs.gov  Website: http://dhs.wisconsin.gov/medicaid/publications/p-
  10095.htm 
Phone: 1-888-549-0820 
 
  Phone: 1-800-362-3002 
 
TEXAS  Medicaid  WYOMING  Medicaid 
   
Website: https://www.gethipptexas.com/  Website: 
 Phone: 1-800-440-0493  http://www.health.wyo.gov/healthcarefin/index.html 
 
Telephone: 307-777-7531 
 
 
To see if any more States have added a premium assistance program since January 22, 2010, or for 
more information on special enrollment rights, you can contact either: 
 
U.S. Department of Labor   U.S. Department of Health and Human Services  
Employee Benefits Security Administration  Centers for Medicare & Medicaid Services 
www.dol.gov/ebsa   www.cms.hhs.gov                                            
1-866-444-EBSA (3272)  1-877-267-2323, Ext. 61565  
 
 
 
OMB Control Number 1210-0137 (expires 07/31/2010)   
  5808  Federal Register/Vol. 75, No. 23/Thursday, February 4, 2010/Notices 
Applications for Secretarial  Agency: Mine Safety and Health  under Medicaid and the Childrens 
certification must be submitted to the  Administration.  Health Insurance Program (CHIP). The 
MSHA Qualification and Certification  Title: Qualification and Certification  Department of Labor (Department) is 
Unit in Denver, Colorado. MSHA Form  of Electrical Training.  required to provide the model notice to 
50001 provides the coal mining  OMB Number: 12190001.  employers within one year of CHIPRAs 
industry with a standardized reporting  Recordkeeping: MSHA Form 50001  enactment. This document announces 
format that expedites the certification  is used by instructors, who may be  the availability of a Model Employer 
process while ensuring compliance with  mining personnel, consultants, or  CHIP Notice. This notice also requests 
the regulations. The information  college professors, to report to MSHA  comments regarding compliance with 
provided on the forms enables the  those miners who have satisfactorily  the Employer CHIP Notice requirement 
Secretary of Labors delegateMSHA,  completed a coal mine electrical  for use in the development of future 
Qualification and Certification Unitto  training program. Based on the  compliance assistance materials and/or 
determine if the applicants satisfy the  information submitted on Form 50001,  regulations. 
requirements to obtain the certification  MSHA issues certification cards that 
DATES: Comment Date: Comments are 
or qualification. Persons must meet  identify these individuals as qualified to 
due on or before April 5, 2010. 
certain minimum experience  perform certain tasks at the mine. 
requirements depending on the type of  Frequency: On Occasion.  ADDRESSES: Written comments may be 
certification or qualification applied for.  Affected Public: Business or other for-  submitted via any of the methods 
profit.  specified below. Please do not submit 
II. Desired Focus of Comments  Respondents: 17,960.  duplicates. All comments will be made 
MSHA is particularly interested in  Responses: 2,796.  available to the public. Warning: Do not 
comments that:  Total Burden Hours: 160.  include any personally identifiable 
 Evaluate whether the proposed  Total Burden Cost (operating/  information (such as name, address, or 
collection of information is necessary  maintaining): $13,124.  other contact information) or 
for the proper performance of the  Comments submitted in response to  confidential business information that 
functions of the agency, including  this notice will be summarized and/or  you do not want publicly disclosed. All 
whether the information will have  included in the request for Office of  comments are posted on the Internet 
practical utility;  Management and Budget approval of the  exactly as received, and can be retrieved 
 Evaluate the accuracy of the  information collection request; they will  by most Internet search engines. No 
also become a matter of public record.  deletions, modifications, or redactions 
agencys estimate of the burden of the 
will be made to the comments received, 
proposed collection of information,  Dated at Arlington, Virginia, this 29th day 
including the validity of the  of January 2010.  as they are public records. Comments 
may be submitted anonymously. 
methodology and assumptions used;  John Rowlett, 
 Enhance the quality, utility, and  Director, Management Services Division.   Federal eRulemaking Portal: http:// 
clarity of the information to be  [FR Doc. 20102407 Filed 2310; 8:45 am]  www.regulations.gov. Follow the 
collected; and  instructions for submitting comments. 
BILLING CODE 451043P 
 Minimize the burden of the   E-mail: EOHPSCA.EBSA@dol.gov. 
collection of information on those who   Mail or Hand Delivery: Office of 
are to respond, including through the  DEPARTMENT OF LABOR  Health Plan Standards and Compliance 
use of appropriate automated,  Assistance, Employee Benefits Security 
electronic, mechanical, or other  Employee Benefits Security  Administration, Room N5653, U.S. 
technological collection techniques or  Administration  Department of Labor, 200 Constitution 
other forms of information technology,  Avenue NW., Washington, DC 20210, 
Publication of Model Notice for 
e.g., permitting electronic submissions  Attention: Employer CHIP Notice. 
Employers to Use Regarding Eligibility 
of responses.  for Premium Assistance Under  Comments will be posted without 
A copy of the proposed information  Medicaid or the Childrens Health  change to http://www.regulations.gov 
collection request can be obtained by  Insurance Program, Notice  and http://www.dol.gov/ebsa, and 
contacting the employee listed in the  available for public inspection at the 
FORFURTHERINFORMATIONsection of this  AGENCY: Employee Benefits Security  Public Disclosure Room, N1513, 
notice, or viewed on the Internet by  Administration, Department of Labor.  Employee Benefits Security 
accessing the MSHA home page  ACTION: Notice of the Availability of the  Administration, 200 Constitution 
(http://www.msha.gov/) and selecting  Model Notice for Employers Regarding  Avenue, NW., Washington, DC 20210. 
RFeudleRse &g.  RDeogcss, .a Onnd  tthhee nn esexlte scctrineegn ,  Pthree mChiuilmd rAensssis Htaenaclteh u Inndsuerr aMnecde icaid or  FAOmRyF UTRuTrHnEeRr oINrF BOeRtMhA BTaIOuNmC, OONfTfiAcCeT o: f 
select Paperwork Reduction Act  Program, with Request for Comments.  Health Plan Standards and Compliance 
Supporting Statement to view 
Assistance, Employee Benefits Security 
documents supporting the Federal  SUMMARY: On February 4, 2009, 
Administration, (202) 6938335. This is 
Register Notice.  President Obama signed the Childrens 
not a toll-free number. 
Health Insurance Program 
III. Current Actions 
Reauthorization Act of 2009 (CHIPRA,  SUPPLEMENTARYINFORMATION: 
CES This request for collection of  Pub. L. 1113). CHIPRA includes a  I. Purpose 
TI information contains provisions  requirement that the Departments of 
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W
KH Type of Review: Extension.  group health plan premium assistance  for the Employer CHIP Notice. 
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II. Coordination of Administration  available in the State in which the  Department that, as of January 22, 2010, 
employee resides for premium  the following States offer one or more 
Section 701(f)(3)(B)(i)(II) of the 
assistance under Medicaid and CHIP for  programs that meet this standard: 
Employee Retirement Income Security 
Act (ERISA), as added by CHIPRA,  health coverage of the employee or the   Alabama, 
requires the Departments of Labor and  employees dependents. These notices   Alaska, 
Health and Human Services, in  are referred to in this document as   Arizona, 
Employer CHIP Notices.   Arkansas, 
consultation with State Medicaid and  ERISA section 701(f)(3)(B)(i)(II)   California, 
CHIP Agencies, to develop model  requires the Department to provide   Colorado, 
language for the Employer CHIP Notice   Florida, 
employers with model language for the 
required under section 701(f)(3)(B)(i) of   Georgia, 
ERISA, section 2701(f)(3)(B)(i) of the  Employer CHIP Notices to enable them   Idaho, 
Public Health Service Act (PHS Act),  to timely comply with this requirement.   Indiana, 
and section 9801(f)(3)(B)(i) of the  The model is required to include   Iowa, 
information on how an employee may   Kansas, 
Internal Revenue Code (Code). 
contact the State in which the employee   Kentucky, 
Section 311(b)(1)(D) of CHIPRA  resides for additional information   Louisiana, 
provides that the Departments of Labor  regarding potential opportunities for   Maine, 
and Health and Human Services shall   Massachusetts, 
premium assistance, including how to 
develop initial model notices as   Minnesota, 
provided under ERISA section  apply for such assistance.   Missouri, 
701(f)(3)(B)(i)(II) and the Department of  Section 311(b)(1)(D) of CHIPRA   Montana, 
Labor shall provide such notices to  provides that the Departments of Labor   Nebraska, 
and Health and Human Services shall   Nevada, 
employers by February 4, 2010, which 
develop the initial model notices under   New Hampshire, 
is one year after the enactment of  ERISA section 701(f)(3)(B)(i)(II), and the   New Jersey, 
CHIPRA.  Department of Labor shall provide such   New Mexico, 
Section 104 of the Health Insurance  notices to employers, by February 4,   New York, 
Portability and Accountability Act of   North Carolina, 
2010. Moreover, each employer is 
1996 (HIPAA) requires the Departments   North Dakota, 
of Labor, the Treasury, and Health and  required to provide the initial annual   Oklahoma, 
Human Services (the Departments) to  notices to such employers employees   Oregon, 
beginning with the first plan year that   Pennsylvania, 
ensure that guidance under the health 
begins after the date on which the initial   Rhode Island, 
coverage provisions of Part 7 of the  model notices are first issued.   South Carolina, 
ERISA, Title XXVII of the PHS Act, and  ERISA section 701(f)(3)(B)(i)(III), PHS   Texas, 
Chapter 100 of the Internal Revenue  Act section 2701(f)(3)(B)(i)(II), and Code   Utah, 
Code,1and issued by the Departments   Vermont, 
section 9801(f)(3)(B)(i)(II) provide that 
that relates to the same matter, be   Virginia, 
administered so as to have the same  an employer may provide the Employer   Washington, 
effect at all times.  CHIP Notice concurrent with the   West Virginia, 
furnishing of materials notifying the   Wisconsin, and 
In accordance with these 
employee of health plan eligibility,   Wyoming. 
requirements, this document has been 
concurrent with materials provided to 
developed in coordination with the  Accordingly, if a group health plan 
the employee in connection with open 
Departments of Health and Human  provides benefits for medical care 
season (or other coverage election 
Services and the Treasury, and in  directly (such as through a health 
process under the plan), or concurrent 
consultation with State Medicaid and  maintenance organization); or through 
with the furnishing of the Summary 
CHIP Agencies.  insurance, reimbursement or otherwise 
Plan Description (SPD) provided under 
to participants, beneficiaries, or 
III. Background  ERISA section 104(b). 
providers in one of these States, the 
Under ERISA section 701(f)(3)(B)(i)(I),  IV. Compliance With the Employer  plan is required to provide the 
PHS Act section 2701(f)(3)(B)(i)(I), and  CHIP Notice and Model Language  Employer CHIP Notice, regardless of the 
section 9801(f)(3)(B)(i)(I) of the Code, as  employers location or principal place of 
A. Employers Subject to the Employer 
added by CHIPRA, an employer that  business (or the location or principal 
CHIP Notice Requirement 
maintains a group health plan in a State  place of business of the group health 
that provides medical assistance under  For purposes of the Employer CHIP  plan, its administrator, its insurer, or 
a State Medicaid plan under title XIX of  Notice requirement, an employer  any other service provider affiliated 
the Social Security Act (SSA), or child  providing benefits (directly or through  with the employer or the plan). This 
health assistance under a State child  insurance, reimbursement, or otherwise)  principle is illustrated by the following 
health plan under title XXI of the SSA,  for medical care in a State is considered  example: 
in the form of premium assistance for  to maintain a group health plan in that  Example 1. (i) Facts. An employer in the 
the purchase of coverage under a group  State. If that State provides medical  District of Columbia sponsors a group health 
health plan, is required to make certain  assistance under a State Medicaid plan,  plan that provides reimbursement for 
disclosures. Specifically, the employer  or child health assistance under a State  medical care to plan participants or 
ES is required to notify each employee of  child health plan, in the form of  beneficiaries residing in the District of 
TIC potential opportunities currently  premium assistance for the purchase of  Columbia, Virginia, Maryland, West Virginia, 
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KH 100 of the Code.  CHIP offices, has informed the  requirement. 
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B. Employees Entitled to Notice  workforce may modify the Model  (including, for example, enrollment 
Employer CHIP Notice to its employees.  packets, open season materials, or the 
An Employer CHIP Notice must 
However, employers should be mindful  plan SPD) that may be provided in 
inform each employee, regardless of 
of the requirement to include at least the  advance of the upcoming plan year. 
enrollment status, of potential 
minimum relevant State contact  This principle is illustrated by the 
opportunities for premium assistance in 
information for any employee residing  following example: 
the State in which the employee resides. 
in a State with premium assistance. 
The State is which the employee resides  Example 3. (i) Facts. An employer 
The employer CHIP disclosure 
may or may not be the same as the State  maintains a group health plan with a plan 
in which the employer, the employers  requirement in ERISA, the PHS Act, and  year beginning January 1, 2011. The plan has 
the Code requires that the notice inform  an annual open enrollment season that 
principal place of business, the health 
employees of potential opportunities for  occurs from October 15, 2010 through 
plan, its insurer, or other service 
premium assistance currently  November 30, 2010 with coverage effective 
providers are located. This principle is  available. CHIPRA section 311(b)(1)(D)  January 1, 2011. Open season packets are to 
illustrated by the following example:  be distributed on October 1, 2010 to all 
requires the Department of Labor to 
employees of the employer. 
Example 2. (i) Facts. Same facts as  provide initial model notices within 
(ii) Conclusion. In this Example 3, the 
Example 1, above.  one year of CHIPRAs enactment. 
employer may distribute the Employer CHIP 
(ii) Conclusion. In this Example 2, 
Employers are required to provide  notice as a separate, prominent document in 
employees residing in Virginia, West 
initial annual notices beginning with  the open season packet on October 1, 2010 
Virginia, and Pennsylvania are entitled to 
the first plan year after the date on  and the notice is required to be provided no 
receive the notice because those three States 
offer premium assistance programs. Of  which such initial model notices are  later than January 1, 2011. 
course, the employer may send the notice to  first issued. The Department, working  The notice must be provided in 
all employees if the employer chooses (for  with the Departments of Health and  writing in a manner calculated to be 
example, if it is administratively easier to  Human Services and the Treasury, and  understood by the average employee. It 
send the notice to all than to distinguish  the States, intends to update its Web site  may be provided by first-class mail. 
between employees based on residency).  annually to reflect any changes in the  Alternatively, it may be provided 
C. Form and Content of Notice  number of States offering premium  electronically to the extent the criteria 
assistance programs (or the contact  of the Departments electronic 
The Model Employer CHIP Notice 
information for those States), to help  disclosure safe harbor at 29 CFR 
was designed as a template to cover an 
enable employers to meet their CHIP  2520.104b1(c) are satisfied. 
array of situations where employees 
disclosure requirements.  CHIPRA requires the notice to be 
may be entitled to notice and may reside 
provided annually. The Department 
(or their families may reside) in States  D. Timing and Delivery of the Notice 
expects to update its Web site with the 
across the nation. Employers may use  Employers are required to provide  list of States that offer premium 
the model template as a national notice  these notices by the date that is the later  assistance programs and provide other 
to fulfill their employer notice  of (1) the first day of the first plan year  additional information annually to help 
disclosure obligation under ERISA  after February 4, 2010; or (2) May 1,  enable employers to meet their 
section 701(f)(3)(B)(i), and the parallel  2010. Accordingly, for plan years  Employer CHIP notice obligations. 
provisions of section 2701(f)(3)(B)(i) of  beginning between from February 4,  Comments regarding the Employer CHIP 
the PHS Act and section 9801(f)(3)(B)(i)  2010 through April 30, 2010, the 
notice requirement are invited. 
of the Code. The notice is required to be  Employer CHIP notice must be provided 
provided automatically, free of charge.  by May 1, 2010. For employers whose  V. Model Employer CHIP Notice 
In consultation with State Medicaid  next plan year begins on or after May 1,  The model Employer CHIP Notice is 
and CHIP offices, some States suggested  2010, the Employer CHIP notice must be  available in modifiable, electronic form 
significant modifications to the template  provided by the first day of the next  on the Departments Web site: http:// 
and more detailed descriptions of their  plan year (January 1, 2011 for calendar  www.dol.gov/ebsa. 
own State programs. Of course, the  year plans). 
Model Employer CHIP Notice is just a  The Employer CHIP notice is not  VI. Additional Information 
model and States may wish to include  required to be provided in a separate  In addition to the Employer CHIP 
additional information on their Web  mailing. Plans may combine  Notice requirement, CHIPRA also 
sites and in their own compliance  information to reduce administrative  provides that, in order for States to 
assistance materials that would  costs, if the other requirements of this  evaluate an employment-based plan to 
encourage further disclosure of any  Notice are met. Thus, the Employer  determine whether premium assistance 
individual State premium assistance  CHIP Notice may be furnished  is a cost effective way to provide 
program. Nonetheless, because  concurrent with enrollment packets,  medical or child health assistance to an 
employees (and their families) may  open season materials, or the plan SPD,  individual, group health plans are 
reside in different States than their  provided that (1) such materials are  required to provide, upon request, 
employer, its principal place of  provided no later than the date  information about their benefits to State 
business, their health plan, its insurer,  determined above, (2) such materials are  Medicaid or CHIP programs. The 
or its other service providers that may  provided to all employees entitled to  Departments, in conjunction with an 
distribute the notice on behalf of the  receive the Employer CHIP Notice, and  advisory committee, are separately 
employer, the approach of the Model  (3) the Employer CHIP Notice appears  developing a model coverage 
ES Employer CHIP Notice is to provide a  separately and in a manner which  coordination disclosure form that will 
C
TI very brief description of premium  ensures that an employee who may be  be issued in the future. States may begin 
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RO descriptions. An employer which is not  significance.  this model form is issued. 
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B1 facing multi-State complexities and who  Accordingly, an employer may  Group health plans and group health 
CL6 wants to provide more comprehensive  provide the Employer CHIP notice  insurance issuers must also offer new 
W
KH State-specific information to its  concurrent with other materials  special enrollment opportunities after 
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CHIPRA. Effective April 1, 2009, plans  OMB has approved the model  Aeronautics and Space Administration, 
and issuers are required to permit  Employer CHIPRA notice information  Washington, DC 205460001. 
employees and dependents who are  collection request pursuant to the 
FORFURTHERINFORMATIONCONTACT: 
eligible for, but not enrolled in, a group  emergency review procedures under 5 
Requests for additional information or 
health plan to enroll in the plan upon:  CFR 1320.13. The public reporting 
copies of the information collection 
(1) Losing eligibility for coverage under  burden for this collection of information 
instrument(s) and instructions should 
a State Medicaid or CHIP program, or (2)  is estimated to average approximately 
be directed to Brenda Maxwell, NASA 
becoming eligible for State premium  30 seconds per respondent. Interested 
PRA Officer, NASA Headquarters, 300 E 
assistance under Medicaid or CHIP. The  parties are encouraged to send 
Street, SW., JF000, Washington, DC 
employee or dependent must request  comments regarding the burden 
20546, (202) 3584616, 
coverage within 60 days of being  estimate or any other aspect of this 
Brenda.Maxwell@nasa.gov. 
terminated from Medicaid or CHIP  collection of information, including 
coverage or within 60 days of being  suggestions for reducing this burden, to  SUPPLEMENTARYINFORMATION: 
determined to be eligible for premium  the U.S. Department of Labor, Office of 
I. Abstract 
assistance. Information is available on  the Chief Information Officer, Attention: 
the Departments Web site at http://  Departmental Clearance Officer, 200  Information is needed to guide 
www.dol.gov/ebsa regarding special  Constitution Avenue, NW., Room  implementation of GLOBE (Global 
enrollment. Information is also available  N1301, Washington, DC 20210 or e-  Learning and Observations to Benefit 
on the Department of Health and  mail DOL_PRA_PUBLIC@dol.gov and  the Environment) based on feedback 
Human Services Web site at http://  reference the OMB Control Number  from participating teachers, students, 
www.cms.hhs.gov.  12100137.  and partners in order to help meet the 
Individuals should contact their  Programs goal of improving student 
States Medicaid or CHIP program to  VIII. Statutory Authority  achievement in mathematics and 
determine if they are eligible for  science. 
Authority: 29 U.S.C. 1027, 1059, 1135, 
Medicaid or CHIP, and to see if their 
State will subsidize group health plan  11611169, 11811183, 1181 note, 1185,  II. Method of Collection 
1185a, 1185b, 1191, 1191a, 1191b, and 1191c; 
premiums. Information is also available  sec. 101(g), Public Law 104191, 110 Stat.  The GLOBE Partner survey is Web- 
by calling 1877KIDS NOW or on the  1936; sec. 401(b), Public Law 105200, 112  based on-line instrument. The survey 
Internet at http://  Stat. 645 (42 U.S.C. 651 note); sec. 101(f),  gathers data on all activities related to 
www.insurekidsnow.gov. If they are  Public Law 110233, 122 Stat. 881; sec. 
GLOBE implementation for the year 
eligible for premium assistance,  512(d), Public Law 110343, 122 Stat. 3765; 
prior to administration of the survey. 
Public Law 110460, 122 Stat. 5123; Public 
individuals must contact their plan 
administrator or employer to take  Law 1113, 123 Stat. 8; Secretary of Labors  III. Data 
Order 62009, 74 FR 21524 (May 7, 2009). 
advantage of the new special enrollment 
Title: GLOBE Program Evaluation. 
opportunity and enroll in the group  Signed at Washington, DC, this 1st day of 
February 2010.  OMB Number: 27000114. 
health plan. 
Individuals needing assistance or  Phyllis C. Borzi,  Type of review: Extension of currently 
with questions about the application of  Assistant Secretary, Employee Benefits  approved collection. 
these provisions to their employment-  Security Administration.  Affected Public: State, Local, or Tribal 
based group health plan can call toll  [FR Doc. 20102409 Filed 2310; 8:45 am]  Government; individuals or households; 
free 1.866.444.3272 (EBSA) to speak to  BILLING CODE 451029P  and not-for-profit institutions. 
a Benefits Advisor. Information is also  Number of Respondents: 258. 
available on EBSAs Web site at  Responses per Respondent: 1. 
http://www.dol.gov/ebsa.  NATIONAL AERONAUTICS AND 
Annual Responses: 258 
SPACE ADMINISTRATION 
VII. Paperwork Reduction Act  Hours per Request: 2. 
Statement  [Notice: (10016)]  Annual Burden Hours: 516. 
According to the Paperwork 
Notice of Information Collection  IV. Request for Comments 
Reduction Act of 1995 (Pub. L. 10413) 
(PRA), no persons are required to  AGENCY: National Aeronautics and  Comments are invited on: (1) Whether 
respond to a collection of information  Space Administration (NASA).  the proposed collection of information 
unless such collection displays a valid  ACTION: Notice of information collection.  is necessary for the proper performance 
OMB control number. The Department  of the functions of NASA, including 
notes that a Federal agency cannot  SUMMARY: The National Aeronautics and  whether the information collected has 
conduct or sponsor a collection of  Space Administration, as part of its  practical utility; (2) the accuracy of 
information unless it is approved by  continuing effort to reduce paperwork  NASAs estimate of the burden 
OMB under the PRA, and displays a  and respondent burden, invites the  (including hours and cost) of the 
currently valid OMB control number,  general public and other Federal  proposed collection of information; (3) 
and the public is not required to  agencies to take this opportunity to  ways to enhance the quality, utility, and 
respond to a collection of information  comment on proposed and/or  clarity of the information to be 
unless it displays a currently valid OMB  continuing information collections, as  collected; and (4) ways to minimize the 
ES control number. See 44 U.S.C. 3507.  required by the Paperwork Reduction  burden of the collection of information 
TIC Also, notwithstanding any other  Act of 1995 (Pub. L. 10413, 44 U.S.C.  on respondents, including automated 
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RO with a collection of information if the  submitted within 60 calendar days from  Comments submitted in response to 
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B1 collection of information does not  the date of this publication.  this notice will be summarized and 
WCL6 display a currently valid OMB control  ADDRESSES: All comments should be  included in the request for OMB 
KH number. See 44 U.S.C. 3512.  addressed to Brenda Maxwell, National  approval of this information collection. 
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