View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1481	ICR Reference No: 202411-0938-013
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: FCHCO
Title: Medicaid Program; Medicare Savings Program Application and Eligibility Determinations (CMS-10891)
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: 01/16/2025
	Date Received in OIRA: 11/29/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years. CMS will submit for review and incorporation the fifteen translated forms via a non-substantive change request in the coming months.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2028	36 Months From Approved
Responses	3,460,750	0	0
Time Burden (Hours)	5,517,157	0	0
Cost Burden (Dollars)	0	0	0

Abstract: States use information collected by SSA on LIS applications, transmitted to states with the consent of an individual completing an application, to determine eligibility for the MSPs. The state Medicaid agency accepts and verifies the information provided on the LIS application (to the extent allowable under the MSP final rule); communicates with the applicant or the authorized representative about any additional information needed to make an MSP determination; makes the MSP eligibility determination; enrolls the individual in an MSP, if eligible; and informs the individual about the rights and responsibilities for applying for full Medicaid eligibility. Applicants include anyone who chooses to apply for LIS and provides consent for their application to be considered for MSPs. Information collected by state Medicaid agencies on an MSP-only application will be used to determine eligibility for MSPs. Applicants are anyone who wants to apply for MSPs. Information collected by the CMS model application for MSPs can be used to determine eligibility for MSPs if a state accepts the model application form. Applicants are anyone who wants to apply for MSPs and lives in a state that accepts the model application. Life insurance information collected by state Medicaid agencies such as the name of the insurance company and policy number is used to help individuals obtain the cash surrender value of life insurance policies in order to determine eligibility for MSPs. Affected individuals are those who apply for MSPs and need to provide documentation for states to evaluate whole life insurance policies. Individuals may refuse to provide consent. The information collection requirements will assist the public to understand information about the MSPs and will assist CMS in ensuring a simplified system of MSP application, eligibility determination, and enrollment.

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

IC Title	Form No.	Form Name
Burden on Individuals and States	CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891	, , , , , , , , , , , , , , , ,

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	3,460,750	3,460,750
Annual Time Burden (Hours)	5,517,157	5,517,157
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Overall (see Table 4 of the Supporting Statement), we estimate a burden of 5,517,157 hours at a cost of $80,267,994. Other than the model MSP application, CMS does not have available any collection/reporting instruments regarding these collections. Each state maintains their own instruments for collections and reporting information from applicants and beneficiaries. For the model MSP application, per MIPPA requirements, CMS needs to translate it into the top 10 languages other than English spoken by Medicare applicants. Based on comments received, CMS has translated the model MSP application into the following 16 languages: Arabic, French, German, Haitian Creole, Hindi, Italian, Japanese, Korean, Polish, Portuguese, Russian, Simplified Chinese, Spanish, Tagalog, Traditional Chinese and Vietnamese. CMS chose these languages based on the languages used in the Medicare Advantage multi-language insert (MLI) and reflect the top 15 non-English languages used in the United States. We have revised the model MSP application based on public comments received and our internal review. We discuss all of those changes in a separate response to comments document.

Annual Cost to Federal Government: $80,664,254

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. Yes

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

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

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