[Medicaid] State Children's Health Insurance Program and Supporting Regulations (CMS-R-308)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-21E; CMS-64.21E; CMS-64.EC; CMS-21PW; and Form Gender, Race, Ethnicity)	Form	Modified	Repair queued
CMS-R-308 - Supporting Statement A (2024 version 6).docx	Supporting Statement A	Uploaded 2025-01-07	Repair queued
CMS-R-308 - Supporting Statement A (2024 version 4).docx	Supporting Statement A	Uploaded 2024-11-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8644	State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180	Form	Modified	Statistical Enrollment Reports Screenshots (Forms: CMS-21E; CMS-64.21E; CMS-64.EC; CMS-21PW; and Form Gender, Race, Ethnicity)
8644	State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180	Instruction	Modified

ICR Details

OMB Control No: 0938-0841	ICR Reference No: 202411-0938-002
Status: Active	Previous ICR Reference No: 202109-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: [Medicaid] State Children's Health Insurance Program and Supporting Regulations (CMS-R-308)
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 with change	Conclusion Date: 03/10/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/15/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2028	36 Months From Approved	03/31/2025
Responses	16,024,071	0	16,024,071
Time Burden (Hours)	803,280	0	803,280
Cost Burden (Dollars)	0	0	0

---

Abstract: States are required to submit title XXI plans and amendments for approval by the Secretary pursuant to section 2102 of the Social Security Act in order to receive funds for initiating and expanding health insurance coverage for uninsured children. States are also required to submit State expenditure and statistical reports, annual reports and State evaluations to the Secretary as outlined in the XXI of the Social Security Act.

---

Authorizing Statute(s): Statute at Large: 21 Stat. 2101
   Statute at Large: 21 Stat. 2106
   Statute at Large: 21 Stat. 2102
   Statute at Large: 21 Stat. 2107
  

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:
	89 FR 64462	08/07/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 88053	11/06/2024
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180	CMS-R-308	Statistical Enrollment Reports Screenshots (Forms: CMS-21E; CMS-64.21E; CMS-64.EC; CMS-21PW; and Form Gender, Race, Ethnicity)

---

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	16,024,071	16,024,071	0	0	0	0
Annual Time Burden (Hours)	803,280	803,280	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:

---

Annual Cost to Federal Government: $10,306

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]? Yes

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: 11/15/2024

---