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

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

⚠️ Notice: This information collection may be referencing outdated material.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 (#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

Information Collection (IC) Details

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:

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 %

	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

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.