State Plan Pre-print for Integrated Medicare and Medicaid Programs (CMS-10251)

Forms and Documents

Document Name	Status
Integrated Care Preprint 1-16-08 revisions track changes.doc Supplementary Document	2008-02-19
Response to Comments on Integrated Care 2008.doc Supplementary Document	2008-02-19
CMS-10251 SMD on IC Preprint.doc Supplementary Document	2008-02-19
CMS-10251 Supporting Statement.doc Supporting Statement A	2008-02-19

IC Document Collections

IC ID	Document Title	Status
184093	State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251) Instruction	New

ICR Details

OMB Control No: 0938-1047	ICR Reference No: 200803-0938-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Plan Pre-print for Integrated Medicare and Medicaid Programs (CMS-10251)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/03/2008
	Date Received in OIRA: 03/11/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2011	36 Months From Approved
Responses	30	0	0
Time Burden (Hours)	600	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Information submitted via the State Plan Amendment(SPA) pre-print will be used by CMS Central and Regional Offices to analyze a State's proposal to implement integrated Medicare and Medicaid programs. The State Plan preprint is an optional document for use by States to highlight the arrangements provided between a State and Medicare Advantage Special Needs Plans that are also providing Medicaid services. State Medicaid Agencies will complete the SPA preprint and submit it to CMS for a comprehensive analysis. The preprint provides the opportunity for States to confirm that their integrated care model complies with both Federal statutory and regulatory requirements. The preprint contains assurances, check-off items, and areas for States to describe policies and procedures for subjects such as enrollment, marketing, and quality assurance.

---

Authorizing Statute(s): None

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:
	72 FR 54043	09/21/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 8877	02/15/2008
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251)	CMS-10251	State Plan Preprint for Integrated Care Programs

---

ICR Summary 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	30	0	0	30	0	0
Annual Time Burden (Hours)	600	0	0	600	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The State Plan Preprint for Integrated Care Programs was developed for States to use on a voluntary basis as a tool to demonstrate and explain the key features of the integrated Medicare and Medicaid programs. The preprint provides an outline of the operational details and Medicaid covered services provided in the integrated programs and requires States to provide assurance of compliance with both Federal and regulatory requirements.

---

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

---

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: 03/11/2008

---