State Plan Pre-print to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10288 SPA Template Addendum on Dental Benefits Under Title XXI	Form and Instruction	New	Available
CMS-10288 State Plan Pre-Print to Implement Required Dental Benefit Supporting Statement.doc	Supporting Statement A	Uploaded 2009-09-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191056	State Plan Preprint to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)	Form and Instruction	New	SPA Template Addendum on Dental Benefits Under Title XXI

ICR Details

OMB Control No: 0938-1076	ICR Reference No: 200910-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan Pre-print to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)
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: 11/16/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/21/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	1,530	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 501 of CHIPRA 2009 amends XXI and requires that "child health assistance provided to a targeted low-income child shall include coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." States that provide coverage in a separate CHIP program may choose between two methods of providing the dental services required in Section 501. The State may define the services in the dental benefit package and demonstrate that it includes all of the required services. Alternatively, the State may provide a dental benefit package that is equivalent to one of the three benchmark packages described in the statute. In order to implement one of these options and comply with the statute, States must amend their State Plan using Enclosure #1.

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Authorizing Statute(s): PL: Pub.L. 113 - 3 501 Name of Law: CHIPRA 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 501 Name of Law: CHIPRA of 2009

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 28249	06/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 46774	09/11/2009
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
State Plan Preprint to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)	CMS-10288	SPA Template Addendum on Dental Benefits Under Title XXI

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ICR Summary of Burden

table that charts list 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)	1,530	0	1,530	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.

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Annual Cost to Federal Government: $22,062

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)? No

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: 10/21/2009

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