Income and Eligibility Verification System Reporting and Supporting Regs. (CMS-R-74)

Forms and Documents

Document Name	Status
Form CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regs. Form	Unchanged
CMS-R- 74 - Supportng Statement A (2022 version 3).docx Supporting Statement A	2022-04-28

IC Document Collections

IC ID	Document Title	Status
8090	Income and Eligibility Verification System Reporting and Supporting Regs. Form	Unchanged

ICR Details

OMB Control No: 0938-0467	ICR Reference No: 202204-0938-011
Status: Received in OIRA	Previous ICR Reference No: 201901-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Income and Eligibility Verification System Reporting and Supporting Regs. (CMS-R-74)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/29/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2022
Responses	3,241	3,241
Time Burden (Hours)	1,082	1,082
Cost Burden (Dollars)	0	0

---

Abstract: This collection is necessary to verify income and eligibility requirements for Medicaid recipients, as required by Section 1137 of the Social Security Act.

---

Authorizing Statute(s): Statute at Large: 16 Stat. 1137
   PL: Pub.L. 110 - 379 3(a)(3) Name of Law: QI Program Supplemental Funding Act of 2008
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 379 3(a)(3) Name of Law: QI Program Supplemental Funding Act of 2008

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 9627	02/22/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 25273	04/28/2022
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Income and Eligibility Verification System Reporting and Supporting Regs.	CMS-R-74	Attachment 4.32-A: Income and Eligibility Verification System (IEVS) - PARIS SPA Template

---

ICR Summary of Burden

	Total Request	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	3,241	3,241	0	0	0	0
Annual Time Burden (Hours)	1,082	1,082	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:

---

Annual Cost to Federal Government: $22,917

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

---

Common Form ICR:  No

---

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: 04/29/2022

---