1932 State Plan Amendment Template (CMS-10120)

Forms and Documents

Document Name	Status
Form CMS-10120 1932 State Plan Amendment Template Form	Modified
CMS-10120 - Supporting Statement A [rev 04-21-2017 by OSORA PRA].docx Supporting Statement A	2017-04-21

IC Document Collections

IC ID	Document Title	Status
8781	1932 State Plan Amendment Template Form	Modified

ICR Details

OMB Control No: 0938-0933	ICR Reference No: 201704-0938-005
Status: Historical Active	Previous ICR Reference No: 201402-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: 1932 State Plan Amendment Template (CMS-10120)
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: 06/21/2017
	Date Received in OIRA: 04/21/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	12	0	15
Time Burden (Hours)	70	0	85
Cost Burden (Dollars)	0	0	0

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Abstract: The State Medicaid Agencies will complete the template. CMS will review the information to determine if the state has met all the requirements under 1932(a)(1)(A) and 42 CFR 438.50. Once the all the requirements are met, the state will be allowed to enroll Medicaid beneficiaries on a mandatory basis into managed care entities without section 1115 or 1915(b) waiver authority.

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Authorizing Statute(s): US Code: 42 USC 438.50 Name of Law: State Plan Requirements
  

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:
	82 FR 6559	01/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15224	03/27/2017
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
1932 State Plan Amendment Template	CMS-10120	1932 State Plan Amendment Template

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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	12	15	0	0	-3	0
Annual Time Burden (Hours)	70	85	0	0	-15	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: Despite the number of revisions made to the document, the burden remains the same. While some questions requiring descriptive responses were added, many were deleted and others were put into simpler “check box” tables and questions. We believe the additional and reduced burden are balanced and result in no net change. Based on more recent data we are adjusting the number of responses from 15/year to 12/year. The result is a burden decrease of -15 hours. As indicated, our per response time estimates are unchanged.

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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)? 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: 04/21/2017

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