Medicaid State Plan Preprint for Use by States When Implementing Section 6505, the Prohibition on Payments to Institutions or Entities Located Outside of the United States

Forms and Documents

Document	Type	Status	Availability
Form CMS-10367 Medicaid State Plan Preprint for Use by States When Implementing Section 6505, the Prohibition on Payments to Institutions or Entities Located Outside of the United States.	Form	New	Available
6505 PRA Supporting Statement on Prohibition on Payments 508 Compliant [rev 03-15-11].doc	Supporting Statement A	Uploaded 2011-03-15	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
197007	Medicaid State Plan Preprint for Use by States When Implementing Section 6505, the Prohibition on Payments to Institutions or Entities Located Outside of the United States.	Form	New

ICR Details

OMB Control No: 0938-1128	ICR Reference No: 201103-0938-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicaid State Plan Preprint for Use by States When Implementing Section 6505, the Prohibition on Payments to Institutions or Entities Located Outside of the United States
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: 05/02/2011
	Date Received in OIRA: 03/21/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved
Responses	56	0	0
Time Burden (Hours)	5	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Patient Protection and Affordable Care Act (Affordable Care Act) requires implementation of Section 6505, Prohibition on Payments to Institutions or Entities Located Outside of the United States. A State Medicaid Director letter will provide guidance to States on this provision and includes as an Enclosure, the Medicaid State Plan Preprint. Within this SMD letter, CMS states that the Medicaid State Plan Preprint is required for States to assure to CMS compliance to the Section 6505 provision. CMS has developed the Medicaid State Plan Preprint for Section 6505 for State convenience.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 6505 Name of Law: Patient Protection and Affordable Care Act
   US Code: 19 USC 1902(a) Name of Law: State Plans for Medical Assistance
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6505 Name of Law: Patient Protection and Affordable Care Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80820	12/23/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 13415	03/11/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicaid State Plan Preprint for Use by States When Implementing Section 6505, the Prohibition on Payments to Institutions or Entities Located Outside of the United States.	CMS-10367	6505 SMD State Plan Preprint submitted for Clearance

---

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	56	0	56	0	0	0
Annual Time Burden (Hours)	5	0	5	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.

---

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: 03/21/2011

---