Medicaid Promoting Interoperability Program Document Templates (CMS-10292)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10292 Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)	Form and Instruction	Modified	Available
CMS-10292 - Supporting Statement A (2021 version 3).docx	Supporting Statement A	Uploaded 2021-02-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192702	Medicaid Promoting Interoperability Program Document Templates	Form and Instruction	Modified	Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
192702	Medicaid Promoting Interoperability Program Document Templates	Instruction	Modified

ICR Details

OMB Control No: 0938-1088	ICR Reference No: 202102-0938-009
Status: Historical Active	Previous ICR Reference No: 201712-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Medicaid Promoting Interoperability Program Document Templates (CMS-10292)
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: 05/04/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/09/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2024	36 Months From Approved	05/31/2021
Responses	56	0	56
Time Burden (Hours)	896	0	896
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection is being requested in order that States can submit documentation to CMS for review and approval in order that States can implement the Medicaid program and draw down Federal financial participation. The American Reinvestment and Recovery Act of 2009 provides States with the flexibility to request funds to develop a health information technology vision and road to get to the ultimate goal of meaningful use of certified EHR technology. We will be sending State Medicaid Directors letters and templates for the SMHP, the PAPD and IAPD to States in an effort to request these changes, if they so choose and to make the process as simple as possible. These documents will be collections of data and therefore, the need for this information request.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 4201 Name of Law: American Reinvestment and Recovery Act of 2009
  

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:
	85 FR 76078	11/27/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 8202	02/04/2021
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 Promoting Interoperability Program Document Templates	CMS-10292	Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)

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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	56	0	0	0	0
Annual Time Burden (Hours)	896	896	0	0	0	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:

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Annual Cost to Federal Government: $17,808

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)? Yes

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: 02/09/2021

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