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Federal forms, ICRs, and supporting documents

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.

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Form and Instruction
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Information Collection (IC) Details

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

Document Type Form No. Form Name Instrument File URL 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 Children’s 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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   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 56 0 56 0 0 0
Annual IC Time Burden (Hours) 6,205 0 6,205 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.