View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0193	ICR Reference No: 202108-0938-008
Status: Historical Active	Previous ICR Reference No: 201902-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Medicaid State Plan Base Plan Pages (CMS-179)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/28/2021
	Date Received in OIRA: 08/25/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2024	36 Months From Approved	04/30/2022
Responses	1,120	0	1,120
Time Burden (Hours)	22,400	0	22,400
Cost Burden (Dollars)	0	0	0

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

IC Title	Form No.	Form Name
State Plan Under Title XIX of the Social Security Act (Base plan pages)	CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179	, , , , , , , , , , , , , , , , , ,

Annual Cost to Federal Government: $356,160

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]? 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? No

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.