CHIPRA 2009, Dental Provider and Benefit Information Posted on Insure Kids Now! Website (CMS-10291)

Forms and Documents

Document Name	Status
Form CMS-10291 Collection of Dental Benefit Information Form	Modified
OMB Crosswalk (2).doc Supplementary Document	2011-11-04
CMS-10291Supporting Statement [rev Nov 2011].doc Supporting Statement A	2011-11-23

IC Document Collections

IC ID	Document Title	Status
189779	Collection of Dental Benefit Information Form	Modified
189778	Collection of Dental Provider Information Other-Provider Information - Disclosure Statement	Modified

ICR Details

OMB Control No: 0938-1065	ICR Reference No: 201111-0938-006
Status: Historical Active	Previous ICR Reference No: 201001-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: CHIPRA 2009, Dental Provider and Benefit Information Posted on Insure Kids Now! Website (CMS-10291)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2011
	Date Received in OIRA: 11/08/2011
Terms of Clearance: The OMB control number (0938-1065) and expiration date must be displayed on data collection instruments approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	01/31/2013
Responses	255	0	255
Time Burden (Hours)	9,690	0	9,180
Cost Burden (Dollars)	0	0	0

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Abstract: This is necessary to collect information on State Medicaid and CHIP dental benefits.

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Authorizing Statute(s): PL: Pub.L. 111 - 3 501 Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 501 Name of Law: Children's Health Insurance Program Reauthorization Act of 2009

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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:
	76 FR 47592	08/05/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 65514	10/21/2011
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Collection of Dental Provider Information	CMS-10291	Insure Kids Now (Provider Data Submission Technical Information)
Collection of Dental Benefit Information	CMS-10291, CMS-10291	Children's Dental Benefits Survey ,   Description of Dental Benefits Provided Under Medicaid and the Children's Health Insurance Program (CHIP)

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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	255	255	0	0	0	0
Annual Time Burden (Hours)	9,690	9,180	510	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:

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Annual Cost to Federal Government: $328,385

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]? 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

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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: 11/08/2011

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