CMS-10293 Supporting Statement

Supporting Statement for Paperwork Reduction Act

Tribal Consultation State Plan Amendment Template

CMS

A. Background

The template outlines the information a State must include in its Medicaid State plan in order to document how it meets the requirements for tribal consultation under section 1902(a)(73) of the Social Security Act (the Act).

B. Justification

1. Need and Legal Basis

Effective July 1, 2009, section 5006 of the American Recovery and Reinvestment Act of 2009 (Recovery Act) amended section 1902(a)(73) of the Act to require that certain States utilize a process for the State to seek advice on a regular, ongoing basis from designees of the Indian Health Service (IHS) and Urban Indian Organizations concerning Medicaid and Children’s Health Insurance Program (CHIP) matters having a direct effect on them. The consultation process is required for the 37 States in which 1 or more Indian Health Programs or Urban Indian Organizations furnish health care services.

This template may be used by these 37 States to document their process for the required tribal consultation. A draft template is attached to a State Medicaid Director and State CHIP Director letter, which provides guidance on implementation of section 5006 of the Recovery Act and its protections for Indians in Medicaid and CHIP, including the requirements for tribal consultation.

2. Information Users

The State Medicaid Agencies in 37 States will complete the template. CMS will review the information to determine if the State has met all the requirements of section 1902(a)(73) of the Act for tribal consultation. If the requirements are met, CMS will approve the amendment to the State’s title XIX plan. For a State to receive Medicaid (title XIX) funding, there must be an approved title XIX state plan.

3. Improved Information Technology

This form is available in electronic format. We expect every submittal to be forwarded to our agency using the electronic format. The document is completed in a user friendly format.

4. Duplication of Similar Information

There is no duplication of similar information.

5. Small Businesses

This collection does not impact small businesses.

6. Less Frequent Collection

Once the amendment is approved, there is no need to resubmit unless changes are made to the method used for tribal consultation. Since the model template outlines the information CMS needs for its review, there should be little need for requests for additional information.

7. Special Circumstances

There are no special circumstances or impediments. The model template is available in electronic format and will be posted on the CMS Internet web site.

8. Federal Register Notice/Outside Consultation

A 60-day Federal Register notice was published on September 4, 2009, attached. CMS has also shared a draft version of this template with both the American Public Heath Services Association and with States.

9. Payment/Gift To Respondent

There is no payment/gift to respondents.

10. Confidentiality

There is no personal identifying information collected in the document. All the information is available to the public.

11. Sensitive Questions

There are no questions of a sensitive nature.

12. Burden Estimate (Total Hours & Wages)

The template has 1 page. We estimate that it will take no longer than 1 hour for a State to complete and submit the template to CMS. The potential number of respondents is 37 States. Once the State plan amendment is approved, the State will only need to resubmit to amend the prior submission, which is anticipated to be infrequent. Therefore, the total burden would be 37 hours during Federal fiscal year 2009, with little impact in subsequent years.

To complete and submit the template, it would cost a State no more than $30 ($30/hr. x 1 hrs). To make an amendment, it would cost $30 ($30/hr x 1 hrs).

13. Capital Costs (Maintenance of Capital Costs)

There are no capital costs.

14. Cost to Federal Government

There is no cost to the Federal Government.

15. Program or Burden Changes

This is a new collection.

16. Publication and Tabulation Dates

There are no plans to publish the information for statistical use.

17. Expiration Date

CMS does not oppose the display of the expiration date.

18. Certification Statement

There are no exceptions to the certification statement.

C. Collection of Information Employing Statistical Methods

The use of statistical methods does not apply to this form.

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