Social Security Office (SSO) Report of State Buy-in Problems (CMS-1957)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1957 SSO Report of State Buy-In Problem (email-based template and instructions)	Form and Instruction	Modified	Repair queued
Form CMS-1957 SSO Report of State Buy-In Problem (email-based template and instructions)	Form and Instruction	Modified	Available
CMS-1957 - Supporting Statement Part A (2026 version 11).docx	Supporting Statement A	Uploaded 2026-07-22	Repair queued
CMS-1957 - Supporting Statement Part A (2026 version 10).docx	Supporting Statement A	Uploaded 2026-05-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221460	SSO Report of State Buy-in Problems	Form and Instruction	Modified	SSO Report of State Buy-In Problem (email-based template and instructions)
221460	SSO Report of State Buy-in Problems	Form and Instruction	Modified	SSO Report of State Buy-In Problem (email-based template and instructions)

ICR Details

OMB Control No: 0938-0035	ICR Reference No: 202605-0938-017
Status: Active	Previous ICR Reference No: 202212-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: Social Security Office (SSO) Report of State Buy-in Problems (CMS-1957)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/24/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/29/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2029	36 Months From Approved	07/31/2026
Responses	1,400	0	1,400
Time Burden (Hours)	467	0	467
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-1957 is issued to facilitate communications among the Social Security District Offices, Medicaid State Agencies and CMS Central Office in the resolution of beneficiary entitlement under State Buy-in. It's used when a problem arises which cannot be resolved through the normal data exchange.

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Authorizing Statute(s): US Code: 42 USC 1395v Name of Law: Agreements with States
  

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 14858	03/27/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 32055	05/29/2026
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
SSO Report of State Buy-in Problems	CMS-1957	SSO Report of State Buy-In Problem (email-based template and instructions)

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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	1,400	1,400	0	0	0	0
Annual Time Burden (Hours)	467	467	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: $0

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: 05/29/2026

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