REVISIONS TO THE MEDICAID STATE PLAN PREPRINT FOR MEDICAID COST SHARING PROVISIONS

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
113070	REVISIONS TO THE MEDICAID STATE PLAN PREPRINT FOR MEDICAID COST SHARING PROVISIONS Form	Migrated

ICR Details

OMB Control No: 0938-0193	ICR Reference No: 198508-0938-014
Status: Historical Inactive	Previous ICR Reference No: 198410-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: REVISIONS TO THE MEDICAID STATE PLAN PREPRINT FOR MEDICAID COST SHARING PROVISIONS
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved and continue	Conclusion Date: 11/22/1985
	Date Received in OIRA: 08/28/1985
Terms of Clearance: THIS REQUEST FOR CLEARANCE IS NOT APPROVED PURSUANT TO 5 CFR 1320.4[b] HHS HAS MAINTAINED THAT THIS REGULATION SHOULD NOT BE INTERPRETED TO REQUIRE IDENTIFICATION OF SUBJECT INDIVIDUALS BY STATES TO PROVIDERS. CLEARANCE REQUEST DOES NOT REFLECT HHS POLICY IN THIS REGARD.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1987	12/31/1987	12/31/1987
Responses	54	0	54
Time Burden (Hours)	3,667	0	3,667
Cost Burden (Dollars)	0	0	0

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Abstract: THIS INFORMATION COLLECTION REFLECTS REGULATORY REVISIONS MADE TO THE MEDICAID COST SHARING PREPRINT. THE REVISED PREPRINT IS REQUIRED TO SPECIFY THE METHOD USED TO COLLECT THE CHARGE, THE BASIS USED TO IDENTIFY THOSE UNABLE TO PAY, AND THE PROCEDURES USED TO IMPLEMENT AND ENFORCE THE EXCLUSIONS FROM COST SHARING.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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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: 1

IC Title	Form No.	Form Name
REVISIONS TO THE MEDICAID STATE PLAN PREPRINT FOR MEDICAID COST SHARING PROVISIONS	HCFA-179

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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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 08/28/1985

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