Improving Quality of Care in Medicaid and CHIP through Increased Access to Preventive Services, State Survey (CMS-10521)

Forms and Documents

Document Name	Status
Form CMS-10521 Preventive Services in Medicaid Survey Form and Instruction	New
PRA package Medicaid prevention survey response to comments 7914.doc Supplementary Document	2014-07-25
Crosswalk (OSORA PRA 7-25-2014).xlsx Supplementary Document	2014-07-25
141014 CMS-10521 - Supporting Statement B rev 7-25-2014 by OSORA PRA Passback back to CMS mbh 101414 clean.docx Supporting Statement B	2014-11-13
CMS-10521 - Supporting Statement A - CLEAN [rev by MBH on 11-14-2014].docx Supporting Statement A	2014-11-14

IC Document Collections

IC ID	Document Title	Status
212468	Preventive Services in Medicaid Survey Form and Instruction	New

ICR Details

OMB Control No: 0938-1260	ICR Reference No: 201407-0938-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Improving Quality of Care in Medicaid and CHIP through Increased Access to Preventive Services, State Survey (CMS-10521)
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: 11/19/2014
	Date Received in OIRA: 07/25/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved
Responses	51	0	0
Time Burden (Hours)	128	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In 2014, CMS plans to conduct a survey of state Medicaid directors that focuses on state coverage of preventive services. The survey is to establish a baseline of covered preventive services by states, to better understand whether incentives impact state coverage of preventive services and to identify which methods of outreach and education are most beneficial to recipients. The collection is critical to the mission of CMS.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4106 Name of Law: Patient Protection and Affordable Care Act/HealthCare and Education Reconciliation Act of 2010
   PL: Pub.L. 111 - 152 1302(b) Name of Law: Patient Protection and Affordable Care Act/HealthCare and Education Reconciliation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 4106 Name of Law: Patient Protection and Affordable Care Act/HealthCare and Education Reconciliation Act of 2010
PL: Pub.L. 111 - 152 1302(b) Name of Law: Patient Protection and Affordable Care Act/HealthCare and Education Reconciliation Act of 2010

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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 20211	04/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 43474	07/25/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Preventive Services in Medicaid Survey	CMS-10521	Preventive Services in Medicaid Survey

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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)	128	0	128	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 colelction. One comment letter was received during the 60-day comment period; our response has been added to this PRA package. While, the burden remains unchanged we added three questions in response to the comments. We do not believe that the added questions warrant any burden adjustments.

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Annual Cost to Federal Government: $112,876

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 07/25/2014

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