View Information Collection Request (ICR) Package
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COMMENT
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Days
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OMB Control No:
0938-0467
ICR Reference No:
202511-0938-019
Status:
Received in OIRA
Previous ICR Reference No:
202204-0938-011
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMCS
Title:
[Medicaid] 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:
11/26/2025
Requested
Previously Approved
Expiration Date
36 Months From Approved
12/31/2025
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:
90 FR 43189
09/08/2025
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 54328
11/26/2025
Did the Agency receive public comments on this ICR?
Yes
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:
$26,182
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
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
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:
11/26/2025
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