Information Collection

Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)

IC 208744 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#20) Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)	Form
FMAP Claiming SPA Instructions.docx	Instruction
CMS-10398 (#20) PERM Pilot Submission Template PERM Pilot Proposal Submission State Template.xlsx	Form
CMS-10398 (#21) Threshold Methodology for Identification of Applicable F FMAP Claiming SPA 9-16-13-Attachments.docx	Form
PERM Supporting Statement.docx PERM - Supporting Statement	IC Document
FMAP Claiming SPA Supporting Statement.docx FMAP Claiming - Supporting Statement	IC Document

IC Title:

Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#20)	PERM Pilot Submission Template	PERM Pilot Proposal Submission State Template.xlsx	Yes	Yes	Fillable Printable
Instruction			FMAP Claiming SPA Instructions.docx	Yes	No	Printable Only
Form	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates	FMAP Claiming SPA 9-16-13-Attachments.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	52	0	0	0	0	0
Annual IC Time Burden (Hours)	2,240	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PERM - Supporting Statement	PERM Supporting Statement.docx	09/19/2013
FMAP Claiming - Supporting Statement	FMAP Claiming SPA Supporting Statement.docx	09/19/2013

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