State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)

Forms and Documents

Document	Type	Status	Availability
CMS-10180 Supporting Statement Part A_2019_final.docx	Supporting Statement A	Uploaded 2020-02-25	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
43677	State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)	Instruction	Modified

ICR Details

OMB Control No: 0938-0988	ICR Reference No: 202002-0938-008
Status: Active	Previous ICR Reference No: 201612-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)
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 without change	Conclusion Date: 06/23/2020
	Date Received in OIRA: 02/26/2020
Terms of Clearance: Prior to use, the OMB control number and expiration date must be added to the online form. In addition, in any future revision, extension, or re-instatement request for this collection, CMS shall give reasonable notice to respondents of 1. Whether responses to the collection of information are voluntary, required to obtain or retain a benefit (citing authority), or mandatory (citing authority) and 2. The nature and extent of confidentiality to be provided, if any (citing authority) (see 5 CFR 1320.8(b)(3)). This notice shall be provided in the manner prescribed by 5 CFR 1320.8(c)(1).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved	06/30/2020
Responses	56	0	56
Time Burden (Hours)	1,792	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:
	84 FR 66910	12/06/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 10443	02/24/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)	CMS-10180	CHIP INCURRED BUT NOT REPORTED (IBNR) 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	56	56	0	0	0	0
Annual Time Burden (Hours)	1,792	392	0	0	1,400	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: The change in burden is due to an increased estimate in the time to complete the form, which resulted in the total burden hours increasing from 392 hours to 1,792 hours.

---

Annual Cost to Federal Government: $5,389

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.     No

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? No

---

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: 02/26/2020

---