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OMB Control No:	ICR Reference No: 202607-0938-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: [Medicaid] Rural Health Transformation (RHT) Program Reporting
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/06/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	200	0
Time Burden (Hours)	20,000	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to New Statute
Annual Number of Responses	200	200
Annual Time Burden (Hours)	20,000	20,000
Annual Cost Burden (Dollars)	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: State awardees are required to complete the data collection quarterly and annually. The reporting template will be disseminated to all 50 State awardees and estimate it will take 80 hours to complete each annual report. In aggregate, we estimate an annual burden of 12,000 hours (50 States x 80 hr/State). We estimate it will take 160 hours to complete each quarterly report. In aggregate, we estimate an annual burden of 8,000 hours (50 States x 160 hr/State x 3 reports/year). The fourth quarterly report for each will be waived in place of the annual report. The total respondent burden is 20,000 hours.

Annual Cost to Federal Government: $188,921

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

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