State Plan Amendment Template for Transitional Medical Assistance for Low-Income Families (CMS-10283)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10283 State Plan Amendment Template for Transitional Medical Assistance for Low-Income Families (CMS-10283)	Form and Instruction	New	Available
CMS-10283 Supporting Statement for TMA.doc	Supporting Statement A	Uploaded 2009-08-28	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
190640	State Plan Amendment Template for Transitional Medical Assistance for Low-Income Families (CMS-10283)	Form and Instruction	New

ICR Details

OMB Control No: 0938-1070	ICR Reference No: 200909-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan Amendment Template for Transitional Medical Assistance for Low-Income Families (CMS-10283)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/13/2009
	Date Received in OIRA: 09/11/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	51	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 5004 of the American Recovery and Reinvestment Act of 2009, Public Law 111-5, amends section 1925 of the Social Security Act effective July 1,2009 to offer States two new options for eligibility requirements under Transitional Medical Assistance. To select either or both of these options, a State Medicaid agency will complete the template page and submit it for approval as part of a State plan amendment. The law also imposes new reporting requirements for States, which are mentioned on the template.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 5004 Name of Law: Extension of Transitional Medical Assistance (TMA)

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 17870	04/17/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 34758	07/17/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
State Plan Amendment Template for Transitional Medical Assistance for Low-Income Families (CMS-10283)	CMS-10283	Section 1925 Transitional Medical Assistance Pre-print

---

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	51	0	51	0	0	0
Annual Time Burden (Hours)	51	0	51	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: This is a new collection.

---

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)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 09/11/2009

---