Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and 21B)

Forms and Documents

Document Name	Status
Form CMS-21 Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI Form	Modified
CMS-21 & 21B - Supporting Statement A [rev 4-28-2014 by OSORA PRA].doc Supporting Statement A	2014-04-28

IC Document Collections

IC ID	Document Title	Status
8399	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI Form	Modified

ICR Details

OMB Control No: 0938-0731	ICR Reference No: 201404-0938-009
Status: Historical Active	Previous ICR Reference No: 201103-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and 21B)
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: 06/12/2014
	Date Received in OIRA: 04/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2014
Responses	448	0	448
Time Burden (Hours)	7,840	0	7,840
Cost Burden (Dollars)	0	0	0

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Abstract: Sections 1905 and 2105 of the Social Security Act provide the authority for collecting this information. States are required to submit the form CMS-21 quarterly to CMS no later than 30 days after the end of the quarter being reported and the form CMS-21B quarterly no later than 45 days prior to the start of each quarter of funds request. These submissions provide CMS with the information necessary to issue the quarterly grant awards, monitor current year expenditure levels, determine the allow ability of State claims for reimbursement, develop CHIP financial management information, provide for State reporting of waiver expenditures, ensure that the federally-established allotment is not exceeded. Further, these forms are necessary in the redistribution and reallocation of unspent funds over the Federally mandated timeframes.

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Authorizing Statute(s): PL: Pub.L. 105 - 33 2105 Name of Law: State Children's Health Insurance
   PL: Pub.L. 105 - 33 2105 Name of Law: Program Payments to States
   PL: Pub.L. 111 - 3 201, 202, and 211 Name of Law: Children's Health Insurance Program Reauthorization Act
   Statute at Large: 21 Stat. 2105 Name of Statute: null
  

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:
	79 FR 8972	02/14/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 22976	04/25/2014
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
Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI	CMS-21, CHIP Budget Report For the Title XXI Program State	Quarterly CHIP Statement of Expenditures for Title XXI Summary Sheet ,   CMS-12B

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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	448	448	0	0	0	0
Annual Time Burden (Hours)	7,840	7,840	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: $128,172

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: 04/28/2014

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