Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, State Option Pre-print to Include Pregnant Women in Title XXI. (CMS-10284)

Forms and Documents

Document Name	Status
Form CMS-10284 CHIPRA State Option Pre-print to include Pregnant Women (CMS-10284) Form	New
CMS-10284 Supporting Statement.DOC Supporting Statement A	2009-07-31

IC Document Collections

IC ID	Document Title	Status
190366	CHIPRA State Option Pre-print to include Pregnant Women (CMS-10284) Form	New

ICR Details

OMB Control No: 0938-1068	ICR Reference No: 200908-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, State Option Pre-print to Include Pregnant Women in Title XXI. (CMS-10284)
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: 09/22/2009
	Date Received in OIRA: 08/19/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved
Responses	40	0	0
Time Burden (Hours)	3,200	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3, ensures that States are able to provide necessary health coverage for uninsured children eligible under the State Children's Health Insurance Program (CHIP). Section 111 of CHIPRA adds a new section 2112 to the Social Security Act (the Act) which gives States the option of providing necessary prenatal, delivery and postpartum care to low-income uninsured pregnant women through an amendment to its State child health plan (CHIP plan) (as described in Section 2112). The purpose of this draft state plan amendment template is to provide states with the format needed so a state may amend their CHIP plan to reflect the coverage of pregnant women.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 111 Name of Law: CHIPRA 2009

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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:
	74 FR 20321	05/01/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 34758	07/17/2009
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
CHIPRA State Option Pre-print to include Pregnant Women (CMS-10284)	CMS-10284	Addendum to State Health Plan Describing Coverage of Pregnant Women

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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	40	0	40	0	0	0
Annual Time Burden (Hours)	3,200	0	3,200	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: This is a new collection.

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Annual Cost to Federal Government: $70,078

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: 08/19/2009

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