State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 (CMS-10190)

Forms and Documents

Document Name	Status
Form CMS-10190 State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies (CMS-10190) Form and Instruction	Modified
Form CMS-10190 State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies Form and Instruction	Modified
PRA Summary of Modifications to DRA Preprints.docx Supplementary Document	2009-10-23
CMS-10190 Supporting Statement.doc Supporting Statement A	2009-10-27

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) Form and Instruction	Modified
180500	State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0993	ICR Reference No: 200910-0938-013
Status: Historical Active	Previous ICR Reference No: 200706-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 (CMS-10190)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/30/2009
	Date Received in OIRA: 10/27/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	12/31/2009
Responses	4,016	0	4,056
Time Burden (Hours)	699	0	723
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): Statute at Large: 19 Stat. 1901 Name of Statute: null
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 41142	08/14/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 54823	10/23/2009
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)	CMS-10190, CMS-10190, CMS-10190, CMS-10190, CMS-10190	DRA 6041 Costsharing Preprint ,   DRA 6042 costsharing preprint ,   nem3 1d ,   Non-Emergency Medical Transportation preprint ,   6044 Benchmark Preprint
State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies	CMS-10190	6043 Costsharing 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	4,016	4,056	0	-40	0	0
Annual Time Burden (Hours)	699	723	0	-24	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden slightly decreased due to fewer States submitting templates annually.

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Annual Cost to Federal Government: $4,665

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: 10/27/2009

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