Children's Health Insurance Program (CHIP) Report on Payables and Receivables

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10180 Children's Health Insurance Program (CHIP) Report on Payables and Receivables	Form	Modified	Available
CMS-10180 Supporting Statement Part A_2016_05-01-17.docx	Supporting Statement A	Uploaded 2017-05-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43677	Children's Health Insurance Program (CHIP) Report on Payables and Receivables	Form	Modified

ICR Details

OMB Control No: 0938-0988	ICR Reference No: 201612-0938-006
Status: Historical Active	Previous ICR Reference No: 201309-0938-030
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10180
Title: Children's Health Insurance Program (CHIP) Report on Payables and Receivables
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: 05/10/2017
	Date Received in OIRA: 12/28/2016
Terms of Clearance: Prior to use, the OMB control number and expiration date must be added to the online form.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	05/31/2017
Responses	56	0	56
Time Burden (Hours)	392	0	392
Cost Burden (Dollars)	0	0	0

---

Abstract: The Chief Financial Officers Act of 1990, as amended by the Government Management and Reform Act of 1994, requires government agencies to produce auditable financial statements. Form CMS-10180 will collect accounting data from the States on Payables and Receivables.

---

Authorizing Statute(s): PL: Pub.L. 101 - 576 3515 Name of Law: Chief Financial Officers Act of 1990
  

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 55203	08/18/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 95615	12/28/2016
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
Children's Health Insurance Program (CHIP) Report on Payables and Receivables	CMS-10180	CHIP INCURRED BUT NOT REPORTED (IBNR) SURVEY

---

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	56	56	0	0	0	0
Annual Time Burden (Hours)	392	392	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:

---

Annual Cost to Federal Government: $10,179

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: 12/28/2016

---