The PACE Organization Application Process in 42 CFR Part 460 (CMS-10631)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10631 Waiver Requests (States)	Form and Instruction	New	Repair queued
Form CMS-10631 Waiver Requests (POs)	Form and Instruction	New	Repair queued
Form CMS-10631 State Readiness Review (States)	Form and Instruction	New	Repair queued
Form CMS-10631 Support of State Readiness Review (POs)	Form and Instruction	New	Repair queued
Form CMS-10631 Application Requirements (POs)	Form and Instruction	New	Repair queued
Summary of Changes_ 962016_FINAL.pdf	Supplementary Document	Uploaded 2016-10-05	Available
CMS-10631 - Supporting Stmt A - Passback4_DMAOResponseToOSORA_03202017 CLEAN.docx	Supporting Statement A	Uploaded 2017-03-21	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
223826	Waiver Requests (States)	Form and Instruction	New
223824	Waiver Requests (POs)	Form and Instruction	New
223823	State Readiness Review (States)	Form and Instruction	New
223822	Support of State Readiness Review (POs)	Form and Instruction	New
223821	Application Requirements (POs)	Form and Instruction	New

ICR Details

OMB Control No: 0938-1326	ICR Reference No: 201610-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: The PACE Organization Application Process in 42 CFR Part 460 (CMS-10631)
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 with change	Conclusion Date: 03/24/2017
	Date Received in OIRA: 10/06/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved
Responses	89	0	0
Time Burden (Hours)	4,576	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Initial application requirements for the PACE program are currently set forth in 42 CFR 460.12 and in the PACE Manual, Ch. 17. Until recently, the submission of initial and SAE PACE applications and supporting information was in paper format. These applications are often hundreds of pages long, expensive to reproduce and transmit, and administratively inefficient, as staff reviewing different parts of the application are located in different physical locations and must receive hard copies of the material. However, beginning in 2016, initial PACE applications are being submitted via a new automated, electronic submission process. As with initial applications, an application also must be submitted for a PO that seeks to expand its service area and/or add a new service site, and with OMB approval, an automated application process will now also be required of PACE organizations submitting service area expansion applications. In pursuing this new information collection package, we are extracting this component only from the existing OMB approval for the PACE program (CMS-R-244, OMB Control Number 0938-0790).

---

Authorizing Statute(s): None

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:
	80 FR 76193	12/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62741	09/12/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Support of State Readiness Review (POs)	CMS-10631	PACE Application
Application Requirements (POs)	CMS-10631	PACE Application
State Readiness Review (States)	CMS-10631	PACE Application
Waiver Requests (POs)	CMS-10631	PACE Application
Waiver Requests (States)	CMS-10631	PACE Application

---

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	89	0	0	89	0	0
Annual Time Burden (Hours)	4,576	0	0	4,576	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: No

Burden Reduction Due to:

Short Statement: While this collection is being submitted to OMB as a ‘‘New’’ package, the collection is not new. The collection is currently approved by OMB under control number 0938-0790 (CMS-R-244). Based on internal review we propose to remove the application from that package but, before doing so, we need approval of the application under a new OMB control number. This will avoid lapses in OMB’s approval along with any violations of the PRA. As is, the currently approved CMS-R-244 package is lengthy and somewhat time consuming to review. We believe the change will help streamline the public and OMB’s review of the application as well as the remaining requirements and burden under the CMS-R-244 package. The change also accounts for the use of improved information technology. Specifically, the PACE application will now be 100 percent electronic; the process for submission of both the application and supporting information was in paper format. These applications are often hundreds of pages long, expensive to reproduce and transmit. Automation of the application will provide for a more organized and streamlined submission and review process.

---

Annual Cost to Federal Government: $74,968

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: 10/06/2016

---