Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10314 Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)	Form	New	Available
CMS-10314 Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2010-09-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194671	Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)	Form	New

ICR Details

OMB Control No: 0938-1108	ICR Reference No: 201009-0938-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)
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: 09/27/2010
	Date Received in OIRA: 09/23/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	102	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Improvements for Patients Act of 2008, P.L. 110-275, Section 115 adds new protection from Medicaid estate recovery. Effective January 1, 2010, Medicare Savings Program benefits (i.e., deductibles, co-pays, coinsurance, and Part A & B premiums) are exempt from estate recovery for qualified dual eligibles, age 55 and over, with dates of service on or after January 1, 2010. To assure State compliance, State Medicaid Agencies are to complete this new State plan preprint and submit it to CMS for approval.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 115 Name of Law: Eliminating Application of Estate Recovery
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 115 Name of Law: Eliminating Application of Estate Recovery

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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:
	75 FR 30030	05/28/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 51463	08/20/2010
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
Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)	CMS-10314	Medicare Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title XIX of the Social Security Act

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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)	102	0	102	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: $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]? No

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: 09/23/2010

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