Monthly State File of Medicaid/Medicare Dual Eligible Enrollees (CMS-10143)

Forms and Documents

Document Name	Status
CMS-10143 - Supporting Statement A (rev 1).docx Supporting Statement A	2018-08-27

IC Document Collections

IC ID	Document Title	Status
8816	Monthly State File of Medicaid/Medicare Dual Eligible Enrollees Instruction	Modified

ICR Details

OMB Control No: 0938-0958	ICR Reference No: 201808-0938-012
Status: Historical Active	Previous ICR Reference No: 201511-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: FCHCO
Title: Monthly State File of Medicaid/Medicare Dual Eligible Enrollees (CMS-10143)
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: 10/26/2018
	Date Received in OIRA: 08/28/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	02/28/2019
Responses	612	0	612
Time Burden (Hours)	4,896	0	6,120
Cost Burden (Dollars)	0	0	0

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Abstract: The monthly file of dual eligible enrollees will be used to determine those duals with drug benefits for the phased down State contribution process required by the Medicare Modernization Act of 2003 (MMA).

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Authorizing Statute(s): PL: Pub.L. 108 - 173 1935(c) Name of Law: State phasedown
  

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:
	83 FR 17554	04/20/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 32667	07/13/2018
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
Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

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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	612	612	0	0	0	0
Annual Time Burden (Hours)	4,896	6,120	0	0	-1,224	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: This 2018 iteration proposes a burden adjustment (per response from 10 to 8 hours) due to automated processes with internal controls in place reports are generated related to file submittals or issues. As a result the total burden is reduced from 6,120 to 4,896 hours. Manual intervention is minimal. The data dictionary has been revised. The changes are non-substantive and have no impact on our currently approved burden estimates. The crosswalk represents the updates/changes between the 2015 and the 2018 versions for Sections 4 thru 7 pertaining to the MMA file. Changes were made to applicable fields to conform to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 to replace the current SSN-based Health Insurance Claim Number (HCIN) with the new Medicare Beneficiary Identifier (MBI). The social security number justification is no longer required.

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Annual Cost to Federal Government: $648,480

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

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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: 08/28/2018

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