CMS-179 Exhibit 1 [rev CMCS 03-27-12 and OSORA 03-29-12]

EXHIBIT 1 - Paperwork Reduction Act Submission Worksheet

Part II – Information Collection Detail

State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments)

The following templates remain unchanged from the prior PRA approval:

Exhibit	Number of Pages	State Plan Section	Description of Document
Exhibit A	10	2 Base plan	Coverage and Eligibility-State/Territories
Exhibit A1	10	2 Base plan	Coverage and Eligibility-State/Territories
Exhibit AA	1	4.19-A	Payment for Inpatient Hospital Services
Exhibit AG	1	4.19(k)(1)	Payment for clinical lab services
Exhibit D	37	2 (Att.)	Attachment 2.2-A to Section 2-Territories
Exhibit E		2 (Supp.)	Supplements 1 -3-Territories
Exhibit F	113	2 (Att.)	Attachment 2.6-A-States
Exhibit G		2 (Supp.)	Supplements 1 through 15-States
Exhibit H	83	2 (Att.)	Attachment 2.6-A-Territories
Exhibit J		2 (Supp.)	Supplements 1 through 15-Territories
Exhibit N	1	4.19-B, page 1a	Payment of Title XVIII Part B Outpatient Psychiatric Services
Exhibit O	5	Supp.1 to Att. 4.19-B	Payment of Medicare Part A and Part B Deductible/Coinsurance
Exhibit R	4	4.31	Disclosure of Information by Providers...
Exhibit S		4.32	Income and Eligibility Verification System
Exhibit T		4.33	Medicaid Eligibility Cards for Homeless Individuals
Exhibit U		4.34	Systematic Alien Verification for Entitlements
	265 pages

The following templates were included in the prior PRA approval and subsequently updated.

Exhibit	Number of Pages	State Plan Section	Description of Document
Exhibit P	1	4.19(c)	Payments for Reserving Beds in Institutions
Exhibit Y	1	4.19-D	Payments for Skilled Nursing and Intermediate Care Facility Services
Exhibit X	1	4.19-B	Payment for Services
	3 pages

The following templates are new and were not included in the prior PRA approval.

Exhibit	Number of Pages	State Plan Section	Description of Document
Exhibit AB	1	4.19(e)	Timely payment of claims
Exhibit AC	1	4.19(f)	Denial of services related to payment of cost sharing
Exhibit AD	1	4.19(g)	Audit of records
Exhibit AE	1	4.19(h)	Documentation and availability of payment rates
Exhibit AF	1	4.19(i)	Sufficiency of payments to ensure access
	5 pages