Information Collection

BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)

IC 212601 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⚠️ Notice: This information collection may be referencing outdated material.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 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
CMS-10398 Performance Indicator Specification Template GEN IC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx	Form and Instruction
CMS-10398 34 Model Application Template and Instructions for State GenIC #34 - Title-XXI-State-Plan-508final (3).docx	Form and Instruction
CMS-10398 Medicaid Adult Quality Measures Template GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template (clean).docx	Form and Instruction
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	IC Document
GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision.docx GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision	IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	IC Document
GenIC #26 Medicaid Adult Quality Measures Template screenshots.docx GenIC #26 Medicaid Adult Quality Measures Template screenshots	IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	IC Document
GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes.docx GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes	IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.pdf GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	IC Document
GenIC#34 - Supporting Statement.docx GenIC#34 - Supporting Statement	IC Document
GenIC#34 - Supporting Statement.docx GenIC#34 - Supporting Statement	IC Document
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement	IC Document
GenIC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx GenIC#35 - Copy of Performance Indicator Specification Template	IC Document
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement	IC Document
GenIC #35 Supporting Statement.docx GenIC #35 Supporting Statement	IC Document
GenIC #35 Supporting Statement.docx GenIC #35 Supporting Statemen	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)

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 and Instruction	CMS-10398	Performance Indicator Specification Template	GEN IC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10398	34 Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Childrenâs Health Insurance Program	GenIC #34 - Title-XXI-State-Plan-508final (3).docx	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10398	Medicaid Adult Quality Measures Template	GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template (clean).docx	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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 Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	6,205	6,205
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx	08/07/2014
GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision	GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision.docx	08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx	08/07/2014
GenIC #26 Medicaid Adult Quality Measures Template screenshots	GenIC #26 Medicaid Adult Quality Measures Template screenshots.docx	08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx	08/07/2014
GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes	GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes.docx	08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk	GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.pdf	08/07/2014
GenIC#34 - Supporting Statement	GenIC#34 - Supporting Statement.docx	08/07/2014
GenIC#34 - Supporting Statement	GenIC#34 - Supporting Statement.docx	08/07/2014
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement	GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx	08/07/2014
GenIC#35 - Copy of Performance Indicator Specification Template	GenIC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx	08/07/2014
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement	GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx	08/07/2014
GenIC #35 Supporting Statement	GenIC #35 Supporting Statement.docx	08/07/2014
GenIC #35 Supporting Statemen	GenIC #35 Supporting Statement.docx	08/07/2014

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