State Collection and Reporting of Dental Provider and Benefit Package Information on the Insure Kids Now! Website and Hotline (CMS-10291)

Forms and Documents

Document Name	Status
Form CMS-10291 Collection of Dental Benefit Information Form	Modified
Form CMS-10291 Collection of Dental Provider Information Form and Instruction	Modified
CMS-10291 - Supporting Statement B (rev 06-14-2018 by OSORA PRA).docx Supporting Statement B	2018-06-14
CMS-10291 - Supporting Statement A (rev OSORA PRA) (Third OIRA Passback) CLEAN.docx Supporting Statement A	2018-06-14

IC Document Collections

IC ID	Document Title	Status
189779	Collection of Dental Benefit Information Form	Modified
189778	Collection of Dental Provider Information Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1065	ICR Reference No: 201801-0938-006
Status: Active	Previous ICR Reference No: 201411-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: State Collection and Reporting of Dental Provider and Benefit Package Information on the Insure Kids Now! Website and Hotline (CMS-10291)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/19/2018
	Date Received in OIRA: 01/23/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved	06/30/2018
Responses	255	0	255
Time Burden (Hours)	11,781	0	10,838
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 501 of CHIPRA required the Secretary to work with States, pediatric dentists, and other dental providers to include, no later than August 4, 2009, on the Insure Kids Now (IKN) website (http://www.insurekidsnow.gov/) and hotline (1-877-KIDS-NOW), a current and accurate list of all such dentists and providers within each State that provide dental services to children enrolled in the State plan (or waiver) under Medicaid or the State child health plan (or waiver) under CHIP, and that States update the information on the dental providers quarterly and the information on their benefit package annually thereafter. CMS works closely with the Health Resources Services Administration (HRSA), which administers the IKN website, to implement this provision of CHIPRA. Collection of data from States commenced in 2009.

---

Authorizing Statute(s): PL: Pub.L. 111 - 3 501 Name of Law: Children's Health Insurance Program Reauthorization Act of 2009
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 501 Name of Law: Children's Health Insurance Program Reauthorization Act of 2009

---

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:
	82 FR 51276	11/03/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 1036	01/03/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Collection of Dental Provider Information	CMS-10291	Provider Data Submission Technical Information
Collection of Dental Benefit Information	CMS-10291	Insure Kids Now Children’s Dental Benefits Survey

---

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	255	255	0	0	0	0
Annual Time Burden (Hours)	11,781	10,838	0	943	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: The burden was increased by 943 hours (18.5 hr x 51 states). The 18 hr per response increase consists of: * -2 hours per year due to making three fields in the provider collection (Services_Mobility; Sedation; and Services_Intellectual_Disability) optional, because it was determined that this information is not readily available to states. * +20 hours per year due to updating provider collection data validation rules to require States to indicate a Program Type (Medicaid or CHIP), and to reject submissions where five percent or more of records are duplicated. * +0.5 hours per year due to updating the benefits collection to include three new fields, including two diagnostic services (Oral health screening or assessment, Assessment of risk for tooth decay), and one treatment service (Anti-microbial treatments that stop decay from spreading).

---

Annual Cost to Federal Government: $373,237

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 01/23/2018

---