Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10398 (#38) Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)	Form	New	Available
Form CMS-10398 (#20) Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)	Form and Instruction	New	Available
Form CMS-10398 BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)	Form and Instruction	New	Available
Form CMS-10398 (#32) Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)	Form	New	Available
Form CMS-10398 (#31) Statewide HCBS Transition Plans (# 31)	Form	New	Available
Form CMS-10398 (#29) Medicaid Premiums and Cost Sharing (#29)	Form	New	Available
Form CMS-10398 (#7) CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7)	Form and Instruction	New	Available
Form CMS-10398 (#28) MMIS APD Template NCCI Coding Initiative (Information Collection #28)	Form	New	Available
Form CMS-10398 (#27) MAGI Conversion Plan Part 2 (GenIC #27)	Form and Instruction	New	Available
Form CMS-10398 (#25) Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)	Form	New	Available
Form CMS-10398 (#22) Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)	Form	New	Available
Form CMS-10398 (#20) Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)	Form	New	Available
Form CMS-10398 (#18) Information Collection #18: Alternative Benefit Plans	Form	New	Available
Form CMS-10398 Collection #15 Medicaid State Plan Eligibility	Form	New	Available
Form CMS-10398 Collection # 16: Federally-Facilitated Marketplace Integration Data Collection Tool	Form	New	Available
Form CMS-10398 (#14) MAGI Conversion Plan (Information Collection #14 )	Form and Instruction	New	Available
Form CMS-10398 #11 Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments	Form and Instruction	New	Available
Form CMS-10398-007 Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction	Form and Instruction	New	Available
Form CMS-10398-004 (GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions	Form	New	Available
Form CMS-10398-001 CHIP Annual Report Template System (CARTs)	Form	New	Source copy available
0938-1148 (CMS-10398) Change Worksheet Request.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2011-11-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213646	Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)	Form	New
213094	Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)	Form and Instruction	New
212601	BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)	Form and Instruction	New
212383	Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)	Form	New
212183	Statewide HCBS Transition Plans (# 31)	Form	New
210812	Medicaid Premiums and Cost Sharing (#29)	Form	New
210670	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7)	Form and Instruction	New
210243	MMIS APD Template NCCI Coding Initiative (Information Collection #28)	Form	New
209427	MAGI Conversion Plan Part 2 (GenIC #27)	Form and Instruction	New
209053	Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)	Form	New
208912	Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)	Form	New
208744	Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)	Form	New
208384	Eligibility and Enrollment Performance Indicators (Collection #19 )	Other-Template	New
207634	Information Collection #18: Alternative Benefit Plans	Form	New
207567	CHIP State Plan Eligibility (ICR #17)	Other-CHIP Eligibility State Plan Templates	New
207375	Collection #15 Medicaid State Plan Eligibility	Form	New
207370	Collection # 16: Federally-Facilitated Marketplace Integration Data Collection Tool	Form	New
206399	MAGI Conversion Plan (Information Collection #14 )	Form and Instruction	New
205792	Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Instruction	New
205036	Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415	Other-null	New
204808	Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments	Form and Instruction	New
203251	Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application	Instruction	New
201951	Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction	Form and Instruction	New
201365	(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions	Form	New
200547	CHIP Annual Report Template System (CARTs)	Form	New

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 201111-0938-009
Status: Historical Active	Previous ICR Reference No: 201109-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/28/2011
	Date Received in OIRA: 11/22/2011
Terms of Clearance: Approved consistent with the understanding that individual collections (GenICs) will be submitted for review and approval prior to initiating those collections. Approval for this generic ICR should not be construed as approval for this particular IC.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	10/31/2014	10/31/2014
Responses	3,360	0	1,120
Time Burden (Hours)	86,240	0	28,747
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 19 Stat. 1915 Name of Statute: null
   Statute at Large: 21 Stat. 2101 Name of Statute: null
   Statute at Large: 21 Stat. 1115 Name of Statute: null
   Statute at Large: 19 Stat. 1901 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38655	07/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 57744	09/16/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 25

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility and Enrollment Performance Indicators (Collection #19 )
Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application	CMS-10398-009, CMS-10398-10, CMS-10398-10, CMS-10398-10, CMS-10398-10, CMS-10398-10, CMS-10398-10, CMS-10398-10	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program ,   List of Frequently Requested Waivers and Expenditure Authorities ,   Benefit Specifications and Provider Qualifications ,   Long Term Services Benefit Specifications and Provider Qualifications ,   Budget Neutrality Form ,   Demonstration Financing Form ,   1115 Demonstration Application Budget Neutrality Table Shell ,   Long Term Services and Supports Form
Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)	CMS-10398 (#22), CMS-10398 (#22), CMS-10398 (#23), CMS-10398 (#23)	Health Home State Plan Amendment ,   Health Homes Administrative Component ,   ACR Supplemental Payment Demonstration Guidance ,   Funding Questions
Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments	CMS-10398 #11, CMS-10398 #12	MAGI-based Eligibility Verification Plan ,   Reimbursement Template - Physician Services (Attachment 4.19-B)
Information Collection #18: Alternative Benefit Plans	CMS-10398 (#18)	Mock-up of Interim Form for Alternative Benefit Plans
Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)	CMS-10398 (#25), CMS-10398 (#26)	Tobacco Cessation Quitline Expenditures - Participation in Medicaid Administration Federal Financial Participation (FFP) ,   Medicaid Adult Core Set Measures Reporting Template in CARTS
Collection # 16: Federally-Facilitated Marketplace Integration Data Collection Tool	CMS-10398	Federally Facilitated Marketplace and State Based Rules Integration Plan (CHIP)
Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction	CMS-10398-007, CMS-10398-006, CMS-10398-008	CHIPRA Cycle II - Outreach and Enrollment Grant Semi-Annual Report Template ,   Medicaid Buy-In Program: 2010 Policy Update ,   Payer Initiated Eligibility/Benefit (PIE) Transaction - DRA Companion Guide
BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)	CMS-10398, CMS-10398, CMS-10398	Performance Indicator Specification Template ,   34 Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children’s Health Insurance Program ,   Medicaid Adult Quality Measures Template
Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)	CMS-10398 (#38), CMS-10398 (#19)	Section 1115 Demonstration Application Template ,   Eligibility and Enrollment Performance Indicator Monthly Report
(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions	CMS-10398-005, CMS-10398-004	Recovery Audit Contractor (RAC) Programs at a Glance (Phase III) ,   State Medicaid Payment Suspensions
Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	CMS-10398 (13), CMS-10398 (13), CMS-10398 (13)	Nursing Facility UPL Guidance ,   Outpatient Hospital UPL Guidance ,   Inpatient Hospital UPL Guidance
MAGI Conversion Plan Part 2 (GenIC #27)	CMS-10398 (#27)	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
MAGI Conversion Plan (Information Collection #14 )	CMS-10398 (#14)	14 MAGI Conversion Plan
Statewide HCBS Transition Plans (# 31)	CMS-10398 (#31)	Sample Template for State Settings’ Analysis
Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415
Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)	CMS-10398 (#20), CMS-10398 (#21)	PERM Pilot Submission Template ,   Threshold Methodology for Identification of Applicable FMAP Rates
Collection #15 Medicaid State Plan Eligibility	CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398, CMS-10398	A1-A3 ,   S10 ,   S14 ,   S21 ,   S25 ,   S28 ,   S30 ,   S32 ,   S33 ,   S50 ,   S51 ,   S52 ,   S53 ,   S54 ,   S55 ,   S57 ,   S59 ,   S88 ,   S89 ,   S94
MMIS APD Template NCCI Coding Initiative (Information Collection #28)	CMS-10398 (#28)	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State's Medicaid Management Information System (MMIS)
Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)	CMS-10398 (#32), CMS-10398 (#33)	Preprint - Provider-Preventable Conditions for Non-Payment under Section 4.19 ,   DRA 6062 (Preprint Attachments 2.2-A and 2.6-A)
Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)	CMS-10398 (#20), CMS-10398 (#20), CMS-10398 (#36), CMS-10398 (#36)	User Guide - PERM Round 1 Findings Submission ,   User Guide - PERM Round 2 Proposal Submission ,   DOMA Same Sex CHIP Template ,   DOMA Same Sex Medicaid Template
CHIP Annual Report Template System (CARTs)	CMS-10398-001, CMS-10398-002, CMS-10398-002, CMS-10398-003	CHIP Annual Report Template System (CARTs) ,   2011 National Summary Data Dictionary ,   2011 Medicaid Managed Care Enrollment Data Dictionary ,   Medicaid Recovery Audit Contractor (RAC) Program
Medicaid Premiums and Cost Sharing (#29)	CMS-10398 (#29)	Medicaid Premiums and Cost Sharing
CHIP State Plan Eligibility (ICR #17)
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7)	CMS-10398 (#7)	Connecting Kids to Coverage Grant Semi-Annual Report Template for Grantees

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	3,360	1,120	0	0	2,240	0
Annual Time Burden (Hours)	86,240	28,747	0	0	57,493	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: The burden that was requested and subsequently approved set out the annual burden when it should have set out the total 3-year burden. Consequently, we request that the number of Responses is corrected to read "3,360" and the Hour burden is corrected to read "86,240." These changes will not affect our burden estimates since those estimates were set out in the ICR's Supporting Statement.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 11/22/2011

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