Initial Request for State Implemented Moratorium Form (CMS-10628)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10628 Initial Request for State Implemented Moratorium	Form and Instruction	Modified	Available
CMS10628 Supporting Statement.docx	Supporting Statement A	Uploaded 2026-04-07	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
224647	State Implemented Moratorium Form	Form and Instruction	Modified	Initial Request for State Implemented Moratorium

ICR Details

OMB Control No: 0938-1328	ICR Reference No: 202604-0938-002
Status: Received in OIRA	Previous ICR Reference No: 202301-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Initial Request for State Implemented Moratorium Form (CMS-10628)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/07/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2026
Responses	5	5
Time Burden (Hours)	25	25
Cost Burden (Dollars)	0	0

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Abstract: Congress has enacted section 1866 (j)(7) of the Social Security Act, which allows for the imposition of temporary moratorium. CMS promulgated 42 CFR 424.570 in order to comply with that statute, which requires that prior to implementing state Medicaid moratoria the state Medicaid agency must notify the Secretary in writing , including all of the details of the moratoria, and obtain the Secretary’s concurrence with the imposition of the moratoria. The “Initial Request for State Medicaid Implemented Moratorium” has been created to collect that data, in a uniform manner, which the states report to CMS when they request a moratorium.

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Authorizing Statute(s): US Code: 42 USC 455.470 Name of Law: Social Security Act
  

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:
	91 FR 2778	01/22/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 17283	04/06/2026
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
State Implemented Moratorium Form	CMS-10628	Initial Request for State Implemented Moratorium

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ICR Summary of Burden

	Total Request	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	5	5	0	0	0	0
Annual Time Burden (Hours)	25	25	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: $1,682

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

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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: 04/07/2026

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