Information Collection

Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction

IC 201951 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398-007 Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction Form and Instruction
PIE - Attachment B Companion Guide - Business Scenarios (2).pdf Instruction
PIE - Attachment C SMD10011 (2).pdf Instruction
CMS-10398-007 CHIPRA Cycle II - Outreach and Enrollment Grant Semi-Ann CHIPRA Cycle II Semi-Annual Template_Final Draft for PRA [rev 04-11-2012 OSORA].doc Form and Instruction
CMS-10398-006 Medicaid Buy-In Program: 2010 Policy Update Medicaid Buy In Program [rev 04-11-2012 OSORA].docx Form and Instruction
CMS-10398-008 Payer Initiated Eligibility/Benefit (PIE) Transaction - PIE - Attachment A PIE Transaction Companion Guide- June 2010 (2).pdf Form and Instruction
Medicaid Buy In Supporting Statement.docx Medicaid Buy-In - Supporting Statement IC Document
CHIPRA Cycle II - Semi Annual Report Supporting Statement March 2012.docx CHIPRA Cycle II Semi-Annual Report Template - Supporting Statement IC Document
PIE Supporting Statement.docx PIE Transaction - Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398-007	CHIPRA Cycle II - Outreach and Enrollment Grant Semi-Annual Report Template	CHIPRA Cycle II Semi-Annual Template_Final Draft for PRA [rev 04-11-2012 OSORA].doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398-006	Medicaid Buy-In Program: 2010 Policy Update	Medicaid Buy In Program [rev 04-11-2012 OSORA].docx	Yes	Yes	Fillable Printable
Instruction			PIE - Attachment B Companion Guide - Business Scenarios (2).pdf	Yes	No	Fillable Printable
Instruction			PIE - Attachment C SMD10011 (2).pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10398-008	Payer Initiated Eligibility/Benefit (PIE) Transaction - DRA Companion Guide	PIE - Attachment A PIE Transaction Companion Guide- June 2010 (2).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	169	0	0	0	0	0
Annual IC Time Burden (Hours)	3,380	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Medicaid Buy-In - Supporting Statement	Medicaid Buy In Supporting Statement.docx	04/11/2012
CHIPRA Cycle II Semi-Annual Report Template - Supporting Statement	CHIPRA Cycle II - Semi Annual Report Supporting Statement March 2012.docx	04/11/2012
PIE Transaction - Supporting Statement	PIE Supporting Statement.docx	04/11/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.