Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167 (CMS-179)

Forms and Documents

Document Name	Status
Form CMS-179 Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167 Form and Instruction	Modified
FMG rev4 19 B supp1 preprint.doc Supplementary Document	2009-01-09
FMG rev4 19 Att 4 19-B sec 24p1a.DOC Supplementary Document	2009-01-09
FMG rev4 19 (k) page 66a.doc Supplementary Document	2009-01-09
FMG4 19b preprint 7-29-08.pdf Supplementary Document	2009-01-09
FMG rev4 19 b - DP Revision 07-17-08.doc Supplementary Document	2009-01-09
FCH rev 431_434.doc Supplementary Document	2009-01-09
Exhibits for Base Plan PRA Pages.doc Supplementary Document	2009-01-09
DEH_Territory-Section2 Base.doc Supplementary Document	2009-01-09
DEH_Territory-2 6-A PRA (2).pdf Supplementary Document	2009-01-09
DEH_Territory-2 2-A PRA508 .pdf Supplementary Document	2009-01-09
DEH_State-Section2 Base.doc Supplementary Document	2009-01-09
DEH_State 2.2-A PRA.doc Supplementary Document	2009-01-09
DEH_State 2 6-A PRA (2).pdf Supplementary Document	2009-01-09
DEH Section 3 pages PRA version 7 10 08.pdf Supplementary Document	2009-01-09
DEH rev PRA Base Plan PRA State-Section2.doc Supplementary Document	2009-01-09
DEH rev 2 PRA Base Plan Territory-Section2.doc Supplementary Document	2009-01-09
DEH rev4 22 Base Plan TPL p69,69a,70.doc Supplementary Document	2009-01-09
DEH rev4 17 Liens Adj Rec p53 No Att.doc Supplementary Document	2009-01-09
DCIS sec 4 39 PASRR.doc Supplementary Document	2009-01-09
DCIS att 4 39B .doc Supplementary Document	2009-01-09
DCIS att 4 39A .doc Supplementary Document	2009-01-09
CMS-179 Supporting Statement.doc Supporting Statement A	2009-01-09

IC Document Collections

IC ID	Document Title	Status
7877	Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0193	ICR Reference No: 200902-0938-006
Status: Historical Active	Previous ICR Reference No: 200711-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167 (CMS-179)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/26/2009
	Date Received in OIRA: 02/09/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved	10/31/2010
Responses	4,681	0	56
Time Burden (Hours)	9,271	0	560
Cost Burden (Dollars)	0	0	0

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Abstract: Form CMS-179 is used by State agencies to transmit State plan material to CMS for approval prior to amending their State plans. The Medicaid State base plan pages and attachments are documents utilized by State and territorial agencies which have the responsibility for administering the Medicaid program. When States or territories seek to change selected pages of their State plans, the page(s) are transmitted to CMS for review and approval prior to amending its State plan. This revision package has two purposes. The first is to revise and update selected pages to comply with Federal laws and regulations. The second is part of an activity to make the Medicaid State plan a web-based document.

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Authorizing Statute(s): US Code: 42 USC 440 Name of Law: 167
   US Code: 42 USC 430.10 Name of Law: null
   US Code: 42 USC 430.20 Name of Law: null
  

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:
	73 FR 49677	08/22/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 77701	12/19/2008
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
Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167	CMS-179	Transmittal Notice of Approval of State Plan Material

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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	4,681	56	0	0	4,625	0
Annual Time Burden (Hours)	9,271	560	0	0	8,711	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: $702,000

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)? No

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: 02/09/2009

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