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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10291 Description of Dental Benefits Provided Under Medicaid and CHIP	Form	Modified	Available
Form CMS-10291 Insure Kids Now Children’s Dental Benefits Survey	Form	Modified	Available
Form CMS-10291 Provider Data Submission Technical Information	Form and Instruction	Modified	Available
CMS-10291 - Supporting Statement B [rev 11-24-2014 by OSORA PRA].docx	Supporting Statement B	Uploaded 2014-12-02	Available
CMS-10291 - Supporting Statement A rev 12-02-2014 by OSORA PRA revised by CMS 2-2-2015 clean [rev OSORA PRA].docx	Supporting Statement A	Uploaded 2015-02-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
189779	Collection of Dental Benefit Information	Form	Modified	Description of Dental Benefits Provided Under Medicaid and CHIP
189779	Collection of Dental Benefit Information	Form	Modified	Insure Kids Now Children’s Dental Benefits Survey
189778	Collection of Dental Provider Information	Form and Instruction	Modified	Provider Data Submission Technical Information

ICR Details

OMB Control No: 0938-1065	ICR Reference No: 201411-0938-011
Status: Historical Active	Previous ICR Reference No: 201111-0938-006
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 with change	Conclusion Date: 02/03/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/03/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	36 Months From Approved	02/28/2015
Responses	255	0	255
Time Burden (Hours)	10,838	0	9,690
Cost Burden (Dollars)	0	0	0

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Abstract: Secretary shall work with States, pediatric dentists, and other dental providers to include on the Insure Kids Now (IKN) website (http://www.insurekidsnow.gov/) and hotline (1-877-KIDS-NOW), a current and accurate list of all such dentists and providers within each State that provide dental services to children enrolled in the State plan (or waiver) under Medicaid or the State child health plan (or waiver) under CHIP. Section 501 also requires the Secretary shall ensure that such a list is updated at least quarterly and includes a description of the dental services provided under Medicaid or CHIP, whether the services are provided through a state plan or a waiver. The Secretary shall also post on the IKN website State specific information on available dental benefits. CMS works closely with the Health Resources Services Administration (HRSA), which administers the IKN website, to implement this provision of CHIPRA. The collection commenced in 2009.

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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:
	79 FR 54725	09/12/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 69480	11/21/2014
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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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	255	255	0	0	0	0
Annual Time Burden (Hours)	10,838	9,690	0	1,148	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: ***Dental Provider Data Collection*** Concerning the dental provider data collection, we estimated a total increased burden to states of 36 hours per year (9 hours per quarter) to populate the five new fields in the provider record, to populate the Program Name field which is no longer optional, and to interface with the Program Name/Plan Name validation function, including correcting any errors. We also estimated a one-time increased burden of 0.5 hours to place column headers on all fields and a one-time increased burden of 0.5 hours to reconfigure the IKN Client Tool (only for states that have an out-dated version of the Tool). This is a total increased burden of 37 hours per year from these changes. We also estimated a reduction in burden of 2.25 hours per quarter (or 9 hours annually) due to new features that assist with efficiently managing data and accounts. The net increased burden to states for the dental provider data collection is 28 hours annually (7 hours per quarter) or 1,428 hours (aggregate). The adjusted burden is 9,588 hr (8,160 hr in 2011 + 1,428 hr in 2014). ***Dental Benefit Information Data Collection*** Concerning the dental benefit information data collection, we estimated a 5.5 hour reduction (-280.5 hr aggregate) in the annual burden due to the new electronic forms and submission. The adjusted burden is 1,249.5 hr (1,530 hr in 2011 - 280.5 hr in 2014).

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Annual Cost to Federal Government: $431,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 12/03/2014

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