Social Security Office (SSO) Report of State Buy-in Problems

Forms and Documents

Document Name	Status
Form CMS-1957 Social Security Office (SSO) Report of State Buy-in Problems Form	Modified
Form CMS-1957 Social Security Office (SSO) Report of State Buy-in Problems Form	New
CMS-1957.Supporting Statement Part A.doc Supporting Statement A	2009-10-30

IC Document Collections

IC ID	Document Title	Status
7787	Social Security Office (SSO) Report of State Buy-in Problems Form	Modified
191528	Social Security Office (SSO) Report of State Buy-in Problems Form	New

ICR Details

OMB Control No: 0938-0035	ICR Reference No: 200912-0938-004
Status: Historical Active	Previous ICR Reference No: 200606-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Social Security Office (SSO) Report of State Buy-in Problems
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/05/2010
	Date Received in OIRA: 12/10/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved
Responses	5,600	0	0
Time Burden (Hours)	1,816	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-1957 is issued to facilitate communications among the Social Security District Offices, Medicaid State Agencies and CMS Central Office in the resolution of beneficiary entitlement under State Buy-in. It's used when a problem arises which cannot be resolved through the normal data exchange.

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Authorizing Statute(s): US Code: 42 USC 1395v Name of Law: Agreements with States
  

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 44366	08/28/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 56199	10/30/2009
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
Social Security Office (SSO) Report of State Buy-in Problems	CMS-1957	SSO Report of State Buy-in Problems
Social Security Office (SSO) Report of State Buy-in Problems	CMS-1957	Social Security Office (SSO) Report of State Buy-in Problems

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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	5,600	0	0	0	-1,000	6,600
Annual Time Burden (Hours)	1,816	0	0	0	-550	2,366
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:

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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)? 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: 12/10/2009

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