Exhibits for Base Plan PRA Pages

Exhibit A- “Section 2 –Coverage and Eligibility (States and Territories)” - 20 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x20x 56=112
b. Annual Hour Burden	112x2=224	hours	hours	hours	hours
c. Annual Cost Burden	$11,200.00	$	$		$	$0

Exhibit B - “Section 2 –Coverage and Eligibility- Attachments (State)” – 44 pages

12. Allocate the change in burden –( Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x44x x56=246.4
b. Annual Hour Burden	246.4x 2=492	hours	hours	hours	hours
c. Annual Cost Burden	$24,600.00	$	$		$	$0

Exhibit C - “Section 2 –Coverage and Eligibility - Supplements 1 and 3 (State)” – 2 pages

12.Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x2x56= 11.2
b. Annual Hour Burden	11.2x2=22.4	hours	hours	hours	hours
c. Annual Cost Burden	$1120.00	$	$		$	$0

Exhibit D - “Section 2 –Coverage and Eligibility-Attachment 2.2-A to Section 2 (Territories)” – 33 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x33x56=184.8
b. Annual Hour Burden	184.8 x2= 369.6	hours	hours	hours	hours
c. Annual Cost Burden	$18,480.00	$	$		$	$0

Exhibit E – “Section 2 –Coverage and Eligibility – Supplements 1, 2, 3 (Territories)” – 4 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x4x56=22.4
b. Annual Hour Burden	22.4x2=44.8	hours	hours	hours	hours
c. Annual Cost Burden	$2240.00	$	$		$	$0

Exhibit F - “Section 2 –Coverage and Eligibility – Attachment 2.6-A to Section 2 (States)” – 69 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 69x56=386.4
b. Annual Hour Burden	386.4 x2=772.8	hours	hours	hours	hours
c. Annual Cost Burden	$38,640.00	$	$		$	$0

Exhibit G – “Section 2 –Coverage and Eligibility – Supplements 1 through 15 to Attachment 2.6 - A (States)” – 43 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x43x56=240.8
b. Annual Hour Burden	240.8x 2= 481.60	hours	hours	hours	hours
c. Annual Cost Burden	$24,080.00	$	$		$	$0

Exhibit H – “Section 2 –Coverage and Eligibility – Attachment 2.6-A (Territories)” – 50 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x50x56 =280
b. Annual Hour Burden	280 x 2=560	hours	hours	hours	hours
c. Annual Cost Burden	$28,000.00	$	$		$	$0

Exhibit J - “Section 2 –Coverage and Eligibility – Supplements 1 through 15 (Territories)” – 32 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x 32 x 56 = 179.2
b. Annual Hour Burden	179.2 x 2 = 358.4	hours	hours	hours	hours
c. Annual Cost Burden	$17,920.00	$	$		$	$0

Exhibit K - “Section 3 –Services: General Provisions” – 46 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.44 x46 x 56= 2494
b. Annual Hour Burden	2494 x2=4988	hours	hours	hours	hours
c. Annual Cost Burden	$24,940.00	$	$		$	$0

Exhibit L – Section 4.8 – Availability of Agency Program Manuals – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x 56= 5.6
b. Annual Hour Burden	5.6 x .0833 =.46	hours	hours	hours	hours
c. Annual Cost Burden	$23.00	$	$		$	$0

Exhibit M – Section 4.17 – Liens, Adjustments and Recoveries – 9 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x9 x 56= 50.4
b. Annual Hour Burden	50.4 x1.5 =75.6	hours	hours	hours	hours
c. Annual Cost Burden	$3780.00	$	$		$	$0

Exhibit N - Section 4.19-B, page 1a – Payment of Title XVIII Part B Deductible/Coinsurance – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x 56 =5.6
b. Annual Hour Burden	2x 5.6 = 11.2	hours	hours	hours	hours
c. Annual Cost Burden	$560.00	$	$		$	$0

Exhibit O – Supplement 1 to Attachment 4.19-B – Payment of Medicare Part A and Part B Deductible/Coinsurance – 5 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 5 x 56 = 2.8
b. Annual Hour Burden	2.8 x 2= 5.6	hours	hours	hours	hours
c. Annual Cost Burden	$280.00	$	$		$	$0

Exhibit P- Section 4.19 (c) – Payments for Reserving Beds in Institutions – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x 56 = 5.6
b. Annual Hour Burden	3 x 5.6 = 16.8	hours	hours	hours	hours
c. Annual Cost Burden	$840.00	$	$		$	$0

Exhibit Q – Section 4.22 – Third Party Liability – 5 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x5 x 56 = 28
b. Annual Hour Burden	28 x 2 = 56	hours	hours	hours	hours
c. Annual Cost Burden	$2800.00	$	$		$	$0

Exhibit R – Section 4.31 – Disclosure of Information by Providers – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 56 = 5.6
b. Annual Hour Burden	5.6 x.0833 =.466	hours	hours	hours	hours
c. Annual Cost Burden	$23.32	$	$		$	$0

Exhibit S – Section 4.32 – Income and Eligibility Verification System – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 56 = 5.6
b. Annual Hour Burden	5.6 x.0833 =.466	hours	hours	hours	hours
c. Annual Cost Burden	$23.32	$	$		$	$0

Exhibit T- Section 4.33 Medicaid Eligibility Cards for Homeless Individuals – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 56 = 5.6
b. Annual Hour Burden	5.6 x.0833 =.466	hours	hours	hours	hours
c. Annual Cost Burden	$23.32	$	$		$	$0

Exhibit U – Section 4.34 – Systematic Alien Verification for Entitlements – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 56 = 5.6
b. Annual Hour Burden	5.6 x.0833 =.466	hours	hours	hours	hours
c. Annual Cost Burden	$23.32	$	$		$	$0

Exhibit V- Section 4.39 – PASSR – 1 page

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1x 56 = 5.6
b. Annual Hour Burden	5.6x1= 5.6	hours	hours	hours	hours
c. Annual Cost Burden	$280.00	$	$		$	$0

Exhibit W – Attachments 4.39 –A and B – PASSR – Definition of Specialized Services, Preadmission Screening – 4 pages

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	56 x4 =224
b. Annual Hour Burden	224 x 2=448	hours	hours	hours	hours
c. Annual Cost Burden	$22,400.00	$	$		$	$0

Exhibit AA – Attachment 4.19-A – Payment for Inpatient Hospital Services

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	56
b. Annual Hour Burden	2 x56 = 112	hours	hours	hours	hours
c. Annual Cost Burden	$5600.00	$	$		$	$0

Exhibit X – Attachment 4.19-B – Payment for Services

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	56
b. Annual Hour Burden	2 x 56 = 112	hours	hours	hours	hours
c. Annual Cost Burden	$5600.00	$	$		$	$0

Exhibit Y – Attachment 4.19-D – Payments for Skilled Nursing and Intermediate Care Facility Services

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	56
b. Annual Hour Burden	2x 56 = 112	hours	hours	hours	hours
c. Annual Cost Burden	$5600.00	$	$		$	$0

Exhibit Z - Section 4.19 (k)(1) –Payments to Physicians for Clinical Laboratory Services

12. Allocate the change in burden – (Average estimated burden assuming that any of the 56 States and territories may or may not submit a change to any one of the pages to this established collection once every ten years).

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	.1 x 56 = 5.6
b. Annual Hour Burden	.0833 x 5.6 = .466	hours	hours	hours	hours
c. Annual Cost Burden	$23.32	$	$		$	$0

Exhibit AA -

12. Allocate the change in burden –

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses
b. Annual Hour Burden		hours	hours	hours	hours
c. Annual Cost Burden		$	$		$	$0

Exhibit BB

12. Allocate the change in burden –

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses
b. Annual Hour Burden		hours	hours	hours	hours
c. Annual Cost Burden		$	$		$	$0