Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304/304a)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-304 Reconciliation of State Invoice	Form	Modified	Available
Form CMS-304a Prior Quarter Adjustment Statement	Form	Modified	Available
CMS-304 and 304A Supporting Statement 2009.doc	Supporting Statement A	Uploaded 2009-12-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8261	Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304)	Form	Modified	Reconciliation of State Invoice
8261	Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304)	Other-Other	Modified
46422	Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	Instruction	Modified
46422	Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	Form	Modified	Prior Quarter Adjustment Statement

ICR Details

OMB Control No: 0938-0676	ICR Reference No: 201001-0938-009
Status: Historical Active	Previous ICR Reference No: 200612-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304/304a)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/15/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/27/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2013	36 Months From Approved	03/31/2010
Responses	3,820	0	3,740
Time Burden (Hours)	141,080	0	139,480
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1927 of the Social Security Act requires drug labelers to enter into and have in effect a rebate agreement with CMS for States to receive funding for drugs dispensed to Medicaid recipients.

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Authorizing Statute(s): Statute at Large: 21 Stat. 1927
  

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 28249	06/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 62575	11/30/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304)	CMS-304	Reconciliation of State Invoice
Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	CMS-304a	Prior Quarter Adjustment Statement

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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	3,820	3,740	0	0	80	0
Annual Time Burden (Hours)	141,080	139,480	0	0	1,600	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:

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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: 01/27/2010

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