The Fiscal Soundness Reporting Requirements

Forms and Documents

Document Name	Status
Form CMS-906 The Fiscal Soundness Reporting Requirements (CMS-906) Form and Instruction	Modified
CMS-906_Supporting_Statement_Part_A.doc Supporting Statement A	2012-12-21

IC Document Collections

IC ID	Document Title	Status
8094	The Fiscal Soundness Reporting Requirements (CMS-906) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0469	ICR Reference No: 201301-0938-001
Status: Historical Active	Previous ICR Reference No: 201004-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: The Fiscal Soundness Reporting Requirements
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: 06/10/2013
	Date Received in OIRA: 01/03/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	06/30/2013
Responses	1,281	0	1,039
Time Burden (Hours)	428	0	346
Cost Burden (Dollars)	0	0	0

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Abstract: The information in this collection will be used by the financial review team in order to establish that the MAOs, PDPs, PACE Organizations, 1876 Cost Plans and Demonstration Plans are maintaining fiscally sound organizations.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1857 Name of Statute: null
  

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:
	77 FR 53890	09/04/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 75634	12/21/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
The Fiscal Soundness Reporting Requirements (CMS-906)	CMS-906, CMS-906	Fiscal Soundness-Submission of Financial information page-PRA ,   Submission_page

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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	1,281	1,039	0	242	0	0
Annual Time Burden (Hours)	428	346	0	82	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: For PACE organizations only, CMS is requesting the submission of one additional data element: Total Subordinated Liabilities. The addition of the new data element will actually reduce the time to analyze the financial standing of POs because we will no longer have to contact the POs to establish whether or not the PO's total liabilities calculation includes subordinated debt.

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Annual Cost to Federal Government: $45,525

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: 01/03/2013

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