Information Collection

Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)

IC 213094 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⚠️ Notice: This information collection may be referencing outdated material.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: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)	Form and Instruction
2015 Medicaid Managed Care Rate Guidance 09-3-14.pdf	Instruction
CMS-10398 (#20) User Guide - PERM Round 1 Findings Submission User Guide Round 1 Findings Submission [rev 9-11-2014 by OSORA PRA].docx	Form and Instruction
CMS-10398 (#20) User Guide - PERM Round 2 Proposal Submission User Guide Round 2 Proposal Submission [rev 9-11-2014 by OSORA PRA].docx	Form and Instruction
CMS-10398 (#36) DOMA Same Sex CHIP Template DOMA CHIP SPA Template [rev 9-11-2014 by OSORA PRA].docx	Form
CMS-10398 (#36) DOMA Same Sex Medicaid Template DOMA SPA Template [rev 9-11-2014 by OSORA PRA].docx	Form
Supporting Statement - PERM Pilot Rounds 1 and 2 [rev 9-11-2014 by OSORA PRA].docx Supporting Statement - PERM Pilot	IC Document
Crosswalk for round 1 and 2 proposal.xlsx Crosswalk - PERM Round 1 and 2 Proposal Submission	IC Document
StateHealthOfficialLetter (3).pdf PERM SHO Letter	IC Document
Supporting Statement (# 36) - Same Sex Marriage rev 9-11-2014 by OSORA.docx Supporting Statement - DOMA Same Sex	IC Document
Supporting Statement 2015 Managed Care Rate Setting Guidance.docx Supporting Statement - Managed Care Rate Setting	IC Document

IC Title:

Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)

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 (#20)	User Guide - PERM Round 1 Findings Submission	User Guide Round 1 Findings Submission [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398 (#20)	User Guide - PERM Round 2 Proposal Submission	User Guide Round 2 Proposal Submission [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form	CMS-10398 (#36)	DOMA Same Sex CHIP Template	DOMA CHIP SPA Template [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form	CMS-10398 (#36)	DOMA Same Sex Medicaid Template	DOMA SPA Template [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Instruction			2015 Medicaid Managed Care Rate Guidance 09-3-14.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	50	50
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - PERM Pilot	Supporting Statement - PERM Pilot Rounds 1 and 2 [rev 9-11-2014 by OSORA PRA].docx	09/11/2014
Crosswalk - PERM Round 1 and 2 Proposal Submission	Crosswalk for round 1 and 2 proposal.xlsx	09/11/2014
PERM SHO Letter	StateHealthOfficialLetter (3).pdf	09/11/2014
Supporting Statement - DOMA Same Sex	Supporting Statement (# 36) - Same Sex Marriage rev 9-11-2014 by OSORA.docx	09/11/2014
Supporting Statement - Managed Care Rate Setting	Supporting Statement 2015 Managed Care Rate Setting Guidance.docx	09/11/2014

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