Dental Action Plan Template for Medicaid and CHIP Programs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10368 Dental Action Plan Template for Medicaid and CHIP Programs	Form and Instruction	New	Repair queued
Response to Template Comments final.docx	Supplementary Document	Uploaded 2011-12-27	Repair queued
Crosswalk 12-16-11.docx	Supplementary Document	Uploaded 2011-12-27	Repair queued
CMS 10368 - Supporting Statement part A [rev 12-27-11].docx	Supporting Statement A	Uploaded 2011-12-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200696	Dental Action Plan Template for Medicaid and CHIP Programs	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201201-0938-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Dental Action Plan Template for Medicaid and CHIP Programs
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 02/13/2012
	Date Received in OIRA: 01/04/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In an effort to increase the number of Medicaid and CHIP children who have access to dental care and receive preventive dental services, CMS is working with States to implement two national oral health goals. While some States have undertaken oral health improvement activities in recent years, most States will need to undertake additional activities to increase access and prevention in order to meet these goals. CMS will provide States with technical assistance and opportunities to share best practices to assist them in meeting these goals. The purpose of this template is to identify what activities States intend to undertake in order to achieve the new dental goals. We will share these plans with all States to build a national body of knowledge across States. In addition, States are asked to provide information on their existing programs so that CMS can establish a baseline. States are also asked to identify access issues and barriers to care that they are currently facing so CMS can begin to address these issues with technical assistance. CMS is also interested in learning about what efforts States have already undertaken and how successful those efforts were. If a State has begun to implement the CHIPRA dental provisions, CMS is very interested in learning about those activities. This information will be used to assist other States in their efforts to increase access. CMS Dental Health Goals: o Increasing the rate of children enrolled in Medicaid or CHIP who received any preventive dental services by 10 percentage points over a five-year period. To be phased-in: o Increase the rate of children ages 6-9 enrolled in Medicaid or CHIP who receive a dental sealant on a permanent molar tooth by 10 percentage points over a five-year period.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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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 7863	02/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 80372	12/23/2011
Did the Agency receive public comments on this ICR? Yes

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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
Dental Action Plan Template for Medicaid and CHIP Programs	CMS-10368	Dental Action Plan Template for Medicaid and CHIP Programs

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New collection.

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Annual Cost to Federal Government: $269,982

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: 01/04/2012

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