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

Forms and Documents

Document	Type	Status	Availability
CMS-10143 - Supporting Statement Part A - Final rule.docx	Supporting Statement A	Uploaded 2020-05-28	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8816	Monthly State File of Medicaid/Medicare Dual Eligible Enrollees	Instruction	Modified
235245	? 423.910 (One-time System Update)		Modified

ICR Details

OMB Control No: 0938-0958	ICR Reference No: 202005-0938-016
Status: Active	Previous ICR Reference No: 201903-0938-005
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: 10/26/2020
	Date Received in OIRA: 05/28/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	36 Months From Approved	10/31/2021
Responses	648	0	612
Time Burden (Hours)	5,856	0	4,896
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:
0938-AT79	Final or interim final rulemaking	85 FR 25510	05/01/2020

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Monthly State File of Medicaid/Medicare Dual Eligible Enrollees
§ 423.910 (One-time System Update)

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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	648	612	0	36	0	0
Annual Time Burden (Hours)	5,856	4,896	0	960	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: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The package has been revised to account for a one-time system update. This one time system update adds an additional 960 burden hours to the collection.

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Annual Cost to Federal Government: $34,252

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? No

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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: 05/28/2020

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