Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services

Forms and Documents

Document Name	Status
CMS-10344.REVISED Supporting Statement - Part A (4-18-11).doc Supporting Statement A	2011-04-18

IC Document Collections

IC ID	Document Title	Status
195885	Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (Annual - effective 1/1/2012)	New
195884	Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (CMS-10344)	New

ICR Details

OMB Control No: 0938-1127	ICR Reference No: 201101-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services
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 with change	Conclusion Date: 04/25/2011
	Date Received in OIRA: 01/05/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved
Responses	663	0	0
Time Burden (Hours)	1,632	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This provision is mandated by the Affordable Care Act, section 3309. To implement this provision, CMS needs data from the States, identifying full benefit dual-eligible individuals who are receiving home and community-based services. The States will provide these data as a new data value on their monthly MMA Phase Down report. These data are not available from any other source. CMS will use these new data to set the affected beneficiaries' Medicare Part D copayment to zero.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3309 Name of Law: Zero Copay for HCBS
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3309 Name of Law: Zero Copay for HCBS

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ00	Final or interim final rulemaking	76 FR 21432	04/15/2011

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (CMS-10344)
Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (Annual - effective 1/1/2012)

---

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	663	0	663	0	0	0
Annual Time Burden (Hours)	1,632	0	1,632	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: To implement this provision, CMS needs data from the States, identifying full benefit dual-eligible individuals who are receiving home and community-based services.

---

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 01/05/2011

---