Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions (CMS-R-211)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-R-211 Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	Form and Instruction	Modified	Available
Summary of revisions to Supporting Statement [rev 09-23-2012].docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-09-23	Available
Crosswalk of nonsub template changes for CMS-R-211.doc	Supplementary Document	Uploaded 2012-09-23	Available
CMS-R-211 Supporting Statement Resub Rev 09-19-12.doc	Supporting Statement A	Uploaded 2012-09-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8347	Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0707	ICR Reference No: 201209-0938-006
Status: Historical Active	Previous ICR Reference No: 201105-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions (CMS-R-211)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/09/2012
	Date Received in OIRA: 09/24/2012
Terms of Clearance: Previous terms continue: CMS will resumbit this collection in conjunction with any transition to an electronic collection method and will keep OMB updated on progress toward automated or semi-automated SPA systems.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	08/31/2014	08/31/2014
Responses	40	0	40
Time Burden (Hours)	3,200	0	3,200
Cost Burden (Dollars)	0	0	0

---

Abstract: States are required to submit Title XXI plans and amendments for approval by the Secretary pursuant to section 2102 of the Social Security Act in order to receive funds for initiating and expanding health insurance coverage for uninsured children. The model application Template is used to assist States in submitting a State Child Health Plan and amendments to that plan.

---

Authorizing Statute(s): Statute at Large: 21 Stat. 2102 Name of Statute: null
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	CMS-R-211	Template for Child Health Plan Under Title XXI of the Social Security Act Children's Health Insurance Program

---

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	40	40	0	0	0	0
Annual Time Burden (Hours)	3,200	3,200	0	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:

---

Annual Cost to Federal Government: $96,320

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

---

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: 09/24/2012

---