Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)

Forms and Documents

Document Name	Status
Form CMS-10295 Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295) Form and Instruction	Modified
CMS-10295 - Supporting Statement A rev 07-22-2016 by OSORA PRA 09-14-2016 OMB Passback (002)CAHPG edits -- CLEAN.docx Supporting Statement A	2016-09-29

IC Document Collections

IC ID	Document Title	Status
191135	Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1073	ICR Reference No: 201607-0938-012
Status: Historical Active	Previous ICR Reference No: 201306-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)
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: 11/04/2016
	Date Received in OIRA: 07/22/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved	11/30/2016
Responses	200	0	200
Time Burden (Hours)	400	0	400
Cost Burden (Dollars)	0	0	0

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Abstract: The American Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law 111-5, requires that States submit quarterly reports to the Secretary of Health and Human Services in accordance with section 5004(d) Extension of Transitional Medical Assistance (TMA). The reports under section 5004 are required to continue starting May 31, 2013 or until the Federal authority for TMA coverage sunsets; the Medicare Access and CHIP Reauthorization Act of 2015, Public Law 114-10, permanently reauthorized TMA. Each State Medicaid agency will submit its quarterly reports to the appropriate Regional Office of the Centers for Medicare & Medicaid Services. The reports will be compiled and summarized for annual reports to Congress.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 5004 Name of Law: American The Recovery and Reinvestment Act of 2009 (Recovery 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:
	81 FR 29268	05/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46925	07/19/2016
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
Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)	CMS-10295	State Report on the Transitional Medical Assistance

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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	200	200	0	0	0	0
Annual Time Burden (Hours)	400	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: $0

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)? Yes

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: 07/22/2016

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