State Plan preprints to implement Sections of the Deficit Reduction Act of 2006

Forms and Documents

Document Name	Status
Justification for 83-C.doc Justification for No Material/Nonsubstantive Change	2007-06-05
CMS-10190 revised Supporting Statement including third party disclosure.doc Supporting Statement A	2007-06-05

IC Document Collections

IC ID	Document Title	Status
43678	State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies (CMS-10190)	Modified
180500	State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies Other-6043 SMD	New

ICR Details

OMB Control No: 0938-0993	ICR Reference No: 200706-0938-001
Status: Historical Active	Previous ICR Reference No: 200607-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan preprints to implement Sections of the Deficit Reduction Act of 2006
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/15/2007
	Date Received in OIRA: 06/05/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2009	10/31/2009	10/31/2009
Responses	4,056	0	56
Time Burden (Hours)	723	0	56
Cost Burden (Dollars)	0	0	0

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Abstract: The DRA provides states with flexibility to request through the use of State Plan preprints changes in benefit packages, cost-sharing, non-emergency medical transportation services etc. CMS will send State Medicaid Directors letters and State Plan preprints to States in an effort to request these changes. The information collected from the State will be reviewed and approved by CMS in order that States can implement the Medicaid program.

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Authorizing Statute(s): None

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

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies (CMS-10190)
State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies	CMS-10190	6043 Cost Sharing Preprint

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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	4,056	56	0	4,000	0	0
Annual Time Burden (Hours)	723	56	0	667	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden increase is due to provision 6043 of the DRA which requires third-party disclosure from hospitals to beneficiaries. This package has been edited to include the burden associated with the third-party disclosure. No other changes were made to this currently approved collection. OMB requested that CMS revise this package via the 83-C process to include the additional burden.

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Annual Cost to Federal Government: $0

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 06/05/2007

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