Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)

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⚠️ Notice: This information collection may be referencing outdated material.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 (#38) Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38) Form
CMS-10398 (#19) Eligibility and Enrollment Performance Indicator Monthly # 19 - MonthlyReportForm-State.pdf Form
CMS-10398 (#38) Section 1115 Demonstration Application Template Section 1115 Application Template rev 10-23-14 clean.docx Form
Supporting Statement (#19) Eligibility and Enrollment Performace Indicators [rev 10-23-2014 by OSORA PRA].docx Suporting Statement #19 - Eligibility and Enrollment Performance Indicators IC Document
Supporting Statement (# 30) State Reporting Medicaid Payment Suspension [rev 10-23-2014 by OSORA PRA].docx Supporting Statement #30 - State Reporting Medicaid Payment Suspension IC Document
Supporting Statement 2 (#38) Section 1115 Demonstration Long Term Services rev 10-23-2014 by OSORA PRA.docx Suporting Statement # 38 IC Document

Information Collection (IC) Details

IC Title:	Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#38)	Section 1115 Demonstration Application Template	Section 1115 Application Template rev 10-23-14 clean.docx		Yes	Yes	Fillable Printable
Form	CMS-10398 (#19)	Eligibility and Enrollment Performance Indicator Monthly Report	# 19 - MonthlyReportForm-State.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 47	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 66 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,663	1,663
Annual IC Time Burden (Hours)	11,487	11,487
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Suporting Statement #19 - Eligibility and Enrollment Performance Indicators	Supporting Statement (#19) Eligibility and Enrollment Performace Indicators [rev 10-23-2014 by OSORA PRA].docx	10/27/2014
Supporting Statement #30 - State Reporting Medicaid Payment Suspension	Supporting Statement (# 30) State Reporting Medicaid Payment Suspension [rev 10-23-2014 by OSORA PRA].docx	10/27/2014
Suporting Statement # 38	Supporting Statement 2 (#38) Section 1115 Demonstration Long Term Services rev 10-23-2014 by OSORA PRA.docx	10/28/2014

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