Medicaid Report on Payables and Receivables (R-199)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-R-199 Medicaid Report on Payables and Receivables (R-199)	Form	Modified	Available
CMS-R-199 Supporting Statement - Part A_ FInal.docx	Supporting Statement A	Uploaded 2020-02-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43663	Medicaid Report on Payables and Receivables (R-199)	Form	Modified

ICR Details

OMB Control No: 0938-0697	ICR Reference No: 202002-0938-009
Status: Active	Previous ICR Reference No: 201608-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: Medicaid Report on Payables and Receivables (R-199)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/23/2020
	Date Received in OIRA: 02/26/2020
Terms of Clearance: In its next request for extension or revision, CMS shall include in the PRA statement 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).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2023	36 Months From Approved
Responses	56	0	0
Time Burden (Hours)	1,792	0	0
Cost Burden (Dollars)	0	0	0

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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-R-199 will collect accounting data from the States on payables and receivables.

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

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:
	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

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicaid Report on Payables and Receivables (R-199)	CMS-R-199	MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY

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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	0	0	0	0	56
Annual Time Burden (Hours)	1,792	0	0	0	1,400	392
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 increase in the total burden hours from 392 hours to 1,792 hours. This increase was due to an increase in average response time of 32 hours per form due to more accurate estimating.

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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? 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: 02/26/2020

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