Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)

Forms and Documents

Document Name	Status
Form CMS-10300 Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300) Form and Instruction	New
CMS-10300 Supporting Statement for Premium Assistance.doc Supporting Statement A	2010-01-15

IC Document Collections

IC ID	Document Title	Status
191978	Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300) Form and Instruction	New

ICR Details

OMB Control No: 0938-1084	ICR Reference No: 201002-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)
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 with change	Conclusion Date: 03/15/2010
	Date Received in OIRA: 02/04/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2013	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	255	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 301 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3, adds section 2105(c)(10) of the Social Security Acct effective April 1, 2009, to offer States a new option to provide premium assistance subsidies to enroll targeted low-income individuals under age 19, and their parents in qualified employer-sponsored coverage. To elect this option, a State CHIP agency will complete the template pages and submit it for approval as part of a State plan amendment.

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Authorizing Statute(s): PL: Pub.L. 111 - 3 2105 Name of Law: State Option for Providing Premium Assistance
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 2105 Name of Law: State Option for Providing Premium 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
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 52236	10/09/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 67229	12/18/2009
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
Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)	CMS-10300, CMS-10300	Additional State Plan Option for Providing Premium Assistance CHIP Mediciad Template ,   Additional State Plan Option for Providing Premium Assistance CHIP SPA Template

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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	51	0	51	0	0	0
Annual Time Burden (Hours)	255	0	255	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)? 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: 02/04/2010

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