OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Social Security Office (SSO) Report of State Buy-in Problems (CMS-1957)

ICR 202605-0938-017 · OMB 0938-0035 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-1957 SSO Report of State Buy-In Problem (email-based template and instructions) Form and Instruction Modified Available
CMS-1957 - Supporting Statement Part A (2026 version 10).docx Supporting Statement A Uploaded 2026-05-29 Available
IC Document Collections
IC IDCollectionTypeStatusForm
221460 SSO Report of State Buy-in Problems Form and Instruction ModifiedSSO Report of State Buy-In Problem (email-based template and instructions)
ICR Details
0938-0035 202605-0938-017
Received in OIRA 202212-0938-008
HHS/CMS OFM
Social Security Office (SSO) Report of State Buy-in Problems (CMS-1957)
Revision of a currently approved collection   No
Regular 05/29/2026
  Requested Previously Approved
36 Months From Approved 06/30/2026
1,400 1,400
467 467
0 0
The CMS-1957 is issued to facilitate communications among the Social Security District Offices, Medicaid State Agencies and CMS Central Office in the resolution of beneficiary entitlement under State Buy-in. It's used when a problem arises which cannot be resolved through the normal data exchange.
US Code: 42 USC 1395v Name of Law: Agreements with States
  
None
Not associated with rulemaking
  91 FR 14858 03/27/2026
91 FR 32055 05/29/2026
No
1
IC Title Form No. Form Name
SSO Report of State Buy-in Problems CMS-1957 SSO Report of State Buy-In Problem (email-based template and instructions)
  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 1,400 1,400 0 0 0 0
Annual Time Burden (Hours) 467 467 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
    No
    No
No
No
No
No
Mitch Bryman 410 786-5258 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/29/2026