State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments) (CMS-179)

Forms and Documents

Document Name	Status
Form CMS-179 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction	Modified
CMS-179 - Supporting Statement A [rev 06-29-2015 by OSORA PRA].doc Supporting Statement A	2015-06-30

IC Document Collections

IC ID	Document Title	Status
7877	State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0193	ICR Reference No: 201506-0938-016
Status: Historical Active	Previous ICR Reference No: 201305-0938-023
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments) (CMS-179)
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: 10/19/2015
	Date Received in OIRA: 06/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved	10/31/2015
Responses	1,120	0	1,120
Time Burden (Hours)	22,400	0	22,400
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicaid State base plan pages and attachments are documents utilized by State and territorial agencies which have the responsibility for administering the Medicaid program. The Medicaid State plan is comprised of "pages" and organized by subject matter which include Medicaid eligibility (Section 2), services (Section 3), payment for services (Section 4), and general, financial and personnel administration (Sections 1, 5, 6, 7). When States or territories seek to change selected pages of their State plans, the page(s) are transmitted to the Centers for Medicare & Medicaid Services (CMS) for review and approval by the CMS Central and Regional Offices prior to amending its State plan. Associated with the "CMS-179", a one page cover page that is included in every State plan amendment, the base State plan pages contain approximately 150 documents, and the Attachments and Supplements contain approximately 500 documents that correspond to implementing regulations in the CFR and statutes in the Social Security Act. The base and plan page documents have the same OMB approval number as the CMS-179. The present revision of the current collection is to revise and update selected pages to comply with Federal laws and regulations.

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Authorizing Statute(s): US Code: 42 USC 1936 Name of Law: Social Security Act
  

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:
	80 FR 21720	04/20/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 36810	06/26/2015
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
State Plan Under Title XIX of the Social Security Act (Base plan pages)	CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179	Transmittal and Notice of Approval of State Plan Material (e-version) ,   2.1 - 2.7 (State) ,   2.1 - 2.7 (Territory) ,   4.19(a) ,   4.19(e) ,   4.19(f) ,   4.19(g) ,   4.19(h) ,   4.19(i) ,   4.19 (k)(1) ,   Attachment 2.2 A and Supplements 1 - 3 ,   4.19(b): Attachment 4.19 B ,   (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, 5a, 6, 7, 8, 8a, 8b, 8c, 9b, 10, 11, 12, 13, 14, and 15 ,   (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, 7, 8a, 8b, 8c, 9b, 11, 12, 14, and 15 ,   Attachment 4.19-B, Section 24 ,   Attachment 4.19 B, Supplement 1 ,   4.19(c) ,   4.19 (d) ,   4.31, 4.32, 4.33, and 4.34

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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	1,120	1,120	0	0	0	0
Annual Time Burden (Hours)	22,400	22,400	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:

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Annual Cost to Federal Government: $311,942

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: 06/30/2015

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