Social Security Office (SSO) Report of State Buy-in Problems

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1957 SSO Report of State Buy-in Problems	Form	Removed	Available
Form CMS-1957 State Buy-in Reports	Form	New	Available
Form CMS-1957 Social Security Office (SSO) Report of State Buy-in Problems	Form	Removed	Available
CMS-1957 Supporting Statement (2015) Final.docx	Supporting Statement A	Uploaded 2016-05-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7787	Social Security Office (SSO) Report of State Buy-in Problems	Form	Removed	SSO Report of State Buy-in Problems
221460	SSO Report of State Buy-in Problems	Form	New	State Buy-in Reports
191528	Social Security Office (SSO) Report of State Buy-in Problems	Form	Removed	Social Security Office (SSO) Report of State Buy-in Problems

ICR Details

OMB Control No: 0938-0035	ICR Reference No: 201605-0938-009
Status: Historical Active	Previous ICR Reference No: 201305-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-1957
Title: Social Security Office (SSO) Report of State Buy-in Problems
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/16/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/12/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	09/30/2016
Responses	3,936	0	5,600
Time Burden (Hours)	1,312	0	1,816
Cost Burden (Dollars)	0	0	0

---

Abstract: The CMS-1957 is issued to facilitate communications among the Social Security District Offices, Medicaid State Agencies and CMS Central Office in the resolution of beneficiary entitlement under State Buy-in. It's used when a problem arises which cannot be resolved through the normal data exchange.

---

Authorizing Statute(s): US Code: 42 USC 1395v Name of Law: Agreements with States
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 7124	02/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 22272	04/15/2016
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
SSO Report of State Buy-in Problems	CMS-1957	State Buy-in Reports
Social Security Office (SSO) Report of State Buy-in Problems	CMS-1957	Social Security Office (SSO) Report of State Buy-in Problems
Social Security Office (SSO) Report of State Buy-in Problems	CMS-1957	SSO Report of State Buy-in Problems

---

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	3,936	5,600	0	3,936	-5,600	0
Annual Time Burden (Hours)	1,312	1,816	0	1,312	-1,816	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: The number of respondents increased since the last time this information collection was submitted for OMB approval. We have adjusted the burden accordingly. It is assumed that increase in forms received represents a beneficiary making more complaints than usual. The previous submission for approval of 5600 responses and 1816 time in burden hours is incorrect. It was supposed to be 3802 responses and 1267 time in burden hours. With this submission there was an increase from 3802 to 3936 responses due to complaints and an increase in burden hours from 1267 to 1312.

---

Annual Cost to Federal Government: $27,355

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: 05/12/2016

---