Tribal Consultation State Plan Amendment Template (CMS-10293)

Forms and Documents

Document Name	Status
Form CMS-10293 Tribal Consultation State Plan Amendment Template (CMS-10293) Form and Instruction	Modified
CMS-10293.SHO Letter.doc Supplementary Document	2010-05-19
CMS-10293_Supporting_Statement [rev 7-25-2013 by OSORA PRA].doc Supporting Statement A	2013-07-25

IC Document Collections

IC ID	Document Title	Status
193149	Tribal Consultation State Plan Amendment Template (CMS-10293) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1098	ICR Reference No: 201307-0938-027
Status: Historical Active	Previous ICR Reference No: 201006-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 20151
Title: Tribal Consultation State Plan Amendment Template (CMS-10293)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/23/2013
	Date Received in OIRA: 07/30/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved	10/31/2013
Responses	37	0	37
Time Burden (Hours)	37	0	37
Cost Burden (Dollars)	0	0	0

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Abstract: Section 5006 of the American Recovery and Reinvestment Act of 2009, Public Law 111-5, amends section 1902(a)(73)of the Social Security Act effective July 1, 2009, to require States in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of the Indian Health Service and Urban Indian Organization concerning Medicaid matters having a direct impact on them. The State Medicaid agency for each of these States will complete the template page and submit it for approval as part of a State plan amendment, to document how it meets the requirements for tribal consultation.

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Authorizing Statute(s): Statute at Large: 19 Stat. 1902 Name of Statute: null
   PL: Pub.L. 111 - 5 5006 Name of Law: Protections for Indians under Mmedicaid and CHIP
  

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:
	78 FR 31556	05/24/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 45203	07/26/2013
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
Tribal Consultation State Plan Amendment Template (CMS-10293)	CMS-10293	State Plan Amendment Template for Trival Consultation Under Title XIX of the Social Security Act

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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	37	37	0	0	0	0
Annual Time Burden (Hours)	37	37	0	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:

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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]? No

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)? 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: 07/30/2013

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