Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)

Forms and Documents

Document Name	Status
Form CMS-10295 Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295) Form and Instruction	New
CMS-10295-Emergency Justification.docx Supplementary Document	2009-09-16
Disclosure Statement for Section 5004.DOC Supplementary Document	2009-09-16
Disclosure Statement for Section 5001.DOC Supplementary Document	2009-09-16
CMS-10295-Supporting Statement.docx Supporting Statement A	2009-09-16

IC Document Collections

IC ID	Document Title	Status
191135	Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295) Form and Instruction	New

ICR Details

OMB Control No: 0938-1073	ICR Reference No: 200910-0938-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/30/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/30/2009
	Date Received in OIRA: 10/27/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2010	6 Months From Approved
Responses	200	0	0
Time Burden (Hours)	600	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: American The Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law 111-5, requires that States submit quarterly reports to the Secretary of Health and Human Services in accordance with section 5001 Temporary Increase of Medicaid Federal Medical Assistance Percentage (FMAP) and section 5004(d) Extension of Transitional Medical Assistance (TMA). The reports under section 5001 are required for the period of October 1, 2008 - September 30, 2011. The reports under section 5004 are required beginning on July 1, 2009 until the Federal authority for TMA coverage sunsets (now scheduled to sunset on December 31, 2010). Each State Medicaid agency will submit its quarterly reports to the appropriate Regional Office of the Centers for Medicare & Medicaid Services. The reports will be compiled and summarized for annual reports to Congress.

Emergency Justfication: Please see attached supplemental file.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 5004 Name of Law: American The Recovery and Reinvestment Act of 2009 (Recovery Act),
   PL: Pub.L. 111 - 5 5001 Name of Law: American The Recovery and Reinvestment Act of 2009 (Recovery Act),
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 5001 Name of Law: Temporary Increase of Medicaid Federal Medical Assistance Percentage
PL: Pub.L. 111 - 5 5004 Name of Law: Extension of Transitional Medical Assistance

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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
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 46432	09/09/2009
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
Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)	CMS-10295, CMS-10295	State Report on the Use of Increase FMAP Section 5001 of ARRA ,   State Report on the Transitional Medical Assistance Section 5004 of ARRA

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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	200	0	200	0	0	0
Annual Time Burden (Hours)	600	0	600	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: $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)? Yes

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: 10/27/2009

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