Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template (CMS-10536)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Form and Instruction	New	Available
Eligibility Enrollment IAPD Template CMS 10536 - Response to Comments to OMB as of 2014-12-12_clean.doc	Supplementary Document	Uploaded 2014-12-29	Available
CMS-10536 - Supporting Statement A [rev 12-24-2014 by OSORA PRA].docx	Supporting Statement A	Uploaded 2014-12-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214452	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Form and Instruction	New	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template

ICR Details

OMB Control No: 0938-1268	ICR Reference No: 201412-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template (CMS-10536)
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: Approved without change	Conclusion Date: 02/18/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/29/2014
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
Responses	168	0	0
Time Burden (Hours)	2,688	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Act and CMS-2346-F provide 90% Federal financial participation (FFP) to states for the design, development and implementation of Medicaid eligibility determination systems, and 75% FFP for the operation and maintenance of those systems. To receive enhanced FFP for these systems, states must provide further detail on how the proposed system will address the standards and conditions identified in 42 CFR § 433.112(b). In order to justify a request for enhanced FFP to support Medicaid eligibility determination system costs, states must provide sufficient information and documentation in an APD to CMS for review in accordance with 45 CFR § 95.610. The proposed Implementation Advanced Planning Document (IAPD) Template will provide states with an outline of the information necessary to approve an enhanced FFP request.

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Authorizing Statute(s): US Code: 19 USC 1903 Name of Law: FFP for Medicaid Eligibility and Enrollment Systems
  

Citations for New Statutory Requirements: US Code: 19 USC 1903 Name of Law: FFP for Medicaid Eligibility and Enrollment Systems

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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 51571	08/29/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 75815	12/19/2014
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
Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	CMS-10536	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template

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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	168	0	168	0	0	0
Annual Time Burden (Hours)	2,688	0	2,688	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: This is a new information collection request.

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Annual Cost to Federal Government: $19,740

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]? Yes

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: 12/29/2014

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