State Balancing Incentive Payments Program (BIPP)

Forms and Documents

Document Name	Status
Form CMS-10411 State Balancing Incentive Payments Program (BIPP) Application (CMS-10411) Form and Instruction	New
BIPP Emergency Justification [rev 09-09-11].doc Supplementary Document	2011-09-09
Balancing Incentive Program_Supporting Statement - Part A [rev 09-06-11].DOC Supporting Statement A	2011-09-07

IC Document Collections

IC ID	Document Title	Status
199182	State Balancing Incentive Payments Program (BIPP) Application (CMS-10411) Form and Instruction	New

ICR Details

OMB Control No: 0938-1145	ICR Reference No: 201109-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Balancing Incentive Payments Program (BIPP)
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: 09/10/2011
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/09/2011
	Date Received in OIRA: 09/09/2011
Terms of Clearance: Given that applications for participation in the Balancing Incentive Program will be accepted on an ongoing basis beginning through August 1, 2014 CMS must immediately publish a 60-day notice under the standard PRA process in order to ensure that applications can continue to be submitted beyond the 6 months granted with this approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	6 Months From Approved
Responses	56	0	0
Time Burden (Hours)	2,240	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Effective October 1, 2011, the Balancing Incentive Program offers a targeted increase in the Federal Medical Assistance Percentage (FMAP) to States that undertake structural reforms to increase access to non-institutional LTSS. This information collection request contains the application that States must complete in order to be considered for participation in the Program.

Emergency Justfication: The emergency justification is attached.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 10202 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10202 Name of Law: Patient Protection and Affordable Care Act

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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

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
State Balancing Incentive Payments Program (BIPP) Application (CMS-10411)	CMS-10411	State Balancing Incentive Payments Program (BIPP) Application

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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	56	0	56	0	0	0
Annual Time Burden (Hours)	2,240	0	2,240	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: 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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 09/09/2011

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