Initial Request for State Implemented Moratorium Form (CMS-10628)

Forms and Documents

Document Name	Status
Form CMS-10628 State Implemented Moratorium Form Form and Instruction	New
Supporting Statement for Enrollment Moratorium Final cc_May2017.docx Supporting Statement A	2017-05-05

IC Document Collections

IC ID	Document Title	Status
224647	State Implemented Moratorium Form Form and Instruction	New

ICR Details

OMB Control No: 0938-1328	ICR Reference No: 201611-0938-020
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Initial Request for State Implemented Moratorium Form (CMS-10628)
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: 05/05/2017
	Date Received in OIRA: 12/12/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved
Responses	15	0	0
Time Burden (Hours)	75	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Congress has enacted section 1866 (j)(7) of the Social Security Act, which allows for the imposition of temporary moratorium. CMS promulgated 42 CFR 424.570 in order to comply with that statute, which requires that prior to implementing state Medicaid moratoria the state Medicaid agency must notify the Secretary in writing , including all of the details of the moratoria, and obtain the Secretary’s concurrence with the imposition of the moratoria. The “Initial Request for State Medicaid Implemented Moratorium” has been created to collect that data, in a uniform manner, which the states report to CMS when they request a moratorium.

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Authorizing Statute(s): US Code: 42 USC 455.470 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: US Code: 42 USC 455.470 Name of Law: Social Security 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
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 55203	08/18/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 85571	11/28/2016
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 Implemented Moratorium Form	CMS-10628	State Moratoria Request Form

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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	15	0	15	0	0	0
Annual Time Burden (Hours)	75	0	75	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 of information.

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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)? 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: 12/12/2016

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