Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Forms and Documents

Document Name	Status
Form CMS-10398 #34 GenIC #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 (Formerly CMS-R-211) Form	New
Form CMS-10398 (#43) GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398) Form	New
Form CMS-10398 (#44) GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool Form and Instruction	New
Form CMS-10398 (#7) Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting) Form and Instruction	New
Form CMS-10398 (#7) Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145) Form	New
Form CMS-10398 (#35) #35: Eligibility and Enrollment Performance Indicators Form	New
Form CMS-10398 (#7) #7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template Form	New
Form CMS-10398 (#38) (f #38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412) Form and Instruction	New
Form CMS-10398 (#36) #36: Same Sex Marriage Policy Form	New
Form CMS-10398 (#34) (f #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 (CMS-R-211) Form	New
Form CMS-10398 (#33) #33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232) Form	New
Form CMS-10398 (#28) #28: MMIS APD Template NCCI Coding Initiative (CMS-10358) Form and Instruction	New
Form CMS-10398 (#27) #27: MAGI Conversion Plan Part 2 Form and Instruction	New
Form CMS-10398 (#26) #26: Medicaid Adult Core Set Measures Reporting Template in CARTS Form and Instruction	New
Form CMS-10398 (#25) #25: Tobacco Cessation Quitline Expenditures Form	New
Form CMS-10398 (#23) #23: Medicaid Primary Care Payment Increase – State Data Collection Tool Form	New
Form CMS-10398 (#22) #22: Health Home State Plan Amendment (SPA) Form	New
Form CMS-10398 (#21) #21: FMAP Claiming State Plan Amendment Form	New
Form CMS-10398 (#20) #20: Payment Error Rate Measurement (PERM) Pilot Form and Instruction	New
Form CMS-10398 (#19) #19: Eligibility and Enrollment Performance Indicators Form	New
Form CMS-10398 (#18) #18: Alternative Benefit Plans Form	New
Form CMS-10398 (#17) #17 CHIP State Plan Eligibility (MACPro Templates) Form	New
Form CMS-10398 (#15) #15: Medicaid State Plan Eligibility Form	New
Form CMS-10398 (#14) #14: MAGI Conversion Plan Form and Instruction	New
Form CMS-10398 (#12) #12: Increase in Primary Care Services Payments Form	New
Form CMS-10398 (#11) #11: MAGI-Based Eligibility Verification Plan Form	New
Form CMS-10398 (#9) #9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program Form	New
Form CMS-10398 (# 7) #7: CHIPRA Cycle II Outreach and Enrollment Grant Form and Instruction	New
Form CMS-10398 (#6) #6: Medicaid Buy In Payment Suspensions Form and Instruction	New
Form CMS-10398 (#5) #5: Medicaid Payment Suspensions Form	New
Form CMS-10398 (#4) #4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III) Form	New
Form CMS-10398 (#3) #3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II Form	New
Form CMS-10398 (#1) #1: CHIP Annual Report Template System (CARTs) Form	New
Upcoming Packages 7-1-14.pdf Supplementary Document	2014-10-30
CMS-10398 - Supporting Statement for Generic Umbrella [rev 10-30-2014 by OSORA PRA].doc Supporting Statement A	2014-10-30

IC Document Collections

IC ID	Document Title	Status
226959	GenIC #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 (Formerly CMS-R-211) Form	New
225371	Bundle: #7 (Cycle IV and Cycle V), #37 (Managed Care Rate Setting), #50 (Community First Choice State Plan), and #52 (Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Prod Instruction	New
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services) Instruction	New
223503	Bundle: GenICs 37 (Managed Care Rate Setting Guidance), 50 (Community First Choice State Plan), and 51 (Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions) Instruction	New
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets) Instruction	New
221897	GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews Other-Model Online Eligibility Results Page	New
221450	GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services Instruction	New
219037	GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398) Form	New
218238	GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool Form and Instruction	New
218045	#37 (2016 Managed Care Rate Setting Guidance) Instruction	New
217381	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting) Form and Instruction	New
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145) Form	New
214406	#35: Eligibility and Enrollment Performance Indicators Form	New
214399	#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template Form	New
214375	#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412) Form and Instruction	New
214374	#37: Managed Care Rate Setting Guidance Instruction	New
214373	#36: Same Sex Marriage Policy Form	New
214372	#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 (CMS-R-211) Form	New
214371	#33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232) Form	New
214365	#32: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) (CMS-10364) Instruction	New
214360	#30: State Reporting Medicaid Payment Suspension	New
214359	#31: Statewide HCBS Transition Plans Instruction	New
214342	#29: Medicaid Cost Sharing (CMS-R-53) Instruction	New
214338	#28: MMIS APD Template NCCI Coding Initiative (CMS-10358) Form and Instruction	New
214334	#27: MAGI Conversion Plan Part 2 Form and Instruction	New
214332	#26: Medicaid Adult Core Set Measures Reporting Template in CARTS Form and Instruction	New
214331	#25: Tobacco Cessation Quitline Expenditures Form	New
214330	#23: Medicaid Primary Care Payment Increase – State Data Collection Tool Form	New
214329	#24: Medicaid Accountability – Upper Payment Limits Instruction	New
214328	#22: Health Home State Plan Amendment (SPA) Form	New
214322	#21: FMAP Claiming State Plan Amendment Form	New
214321	#20: Payment Error Rate Measurement (PERM) Pilot Form and Instruction	New
214320	#19: Eligibility and Enrollment Performance Indicators Form	New
214319	#18: Alternative Benefit Plans Form	New
214318	#17 CHIP State Plan Eligibility (MACPro Templates) Form	New
214317	#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool Instruction	New
214314	#15: Medicaid State Plan Eligibility Form	New
214301	#14: MAGI Conversion Plan Form and Instruction	New
214296	#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Instruction	New
214295	#12: Increase in Primary Care Services Payments Form	New
214294	#11: MAGI-Based Eligibility Verification Plan Form	New
214293	#10: Section 1115 Demonstration and Waiver Application Instruction	New
214290	#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program Form	New
214287	#8: (PIE) Payer Initiated Eligibility/Benefit Transaction Instruction	New
214286	#7: CHIPRA Cycle II Outreach and Enrollment Grant Form and Instruction	New
214285	#6: Medicaid Buy In Payment Suspensions Form and Instruction	New
214283	#5: Medicaid Payment Suspensions Form	New
214276	#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III) Form	New
214256	#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II Form	New
214255	#2: Medicaid Managed Care Data Collection Instruction	New
214252	#1: CHIP Annual Report Template System (CARTs) Form	New

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 201410-0938-016
Status: Historical Active	Previous ICR Reference No: 201111-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/24/2014
	Date Received in OIRA: 10/30/2014
Terms of Clearance: Approved consistent with the understanding that individual collections (GenICs) will be submitted for review and approval prior to initiating those collections.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved	12/31/2014
Responses	6,720	0	3,360
Time Burden (Hours)	154,104	0	86,240
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 21 Stat. 1115 Name of Statute: null
   Statute at Large: 19 Stat. 1901 Name of Statute: null
   Statute at Large: 21 Stat. 2101 Name of Statute: null
   Statute at Large: 19 Stat. 1915 Name of Statute: null
  

Citations for New Statutory Requirements: Statute at Large: 19 Stat. 1915 Name of Statute: null
Statute at Large: 21 Stat. 2101 Name of Statute: null
Statute at Large: 21 Stat. 1115 Name of Statute: null
Statute at Large: 19 Stat. 1901 Name of Statute: null

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 40105	07/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 62628	10/20/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 51

IC Title	Form No.	Form Name
#15: Medicaid State Plan Eligibility	CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Individuals above 133% FPL ,   Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21 ,   Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance ,   Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children ,   Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility ,   Medicaid Eligibility: General Eligibility Requirements Eligibility Process ,   Medicaid Administration: State Plan Administration/ Designation and Authority ,   Medicaid Eligibility: MAGI-Based Income Methodologies ,   Medicaid Eligibility: AFDC Income Standards ,   Medicaid Eligibility: Presumptive Eligibility by Hospitals ,   Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives ,   Medicaid Eligibility: Mandatory Coverage Pregnant Women ,   Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19 ,   Medicaid Eligibility: Mandatory Coverage Adult Group ,   Medicaid Eligibility: Mandatory Coverage Former Foster Care Children ,   Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives ,   Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis ,   Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents ,   Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services ,   Medicaid Eligibility: Non-Financial Eligibility State Residency
#5: Medicaid Payment Suspensions	CMS-10398 (#5)	Medicaid Payment Suspensions
#35: Eligibility and Enrollment Performance Indicators	CMS-10398 (#35)	Eligibility and Enrollment Performance Indicators Template
#31: Statewide HCBS Transition Plans	CMS-10398 (#31)	Sample Template For State Settings’ Analysis
#36: Same Sex Marriage Policy	CMS-10398 (#36), CMS-10398 (#36)	DOMA Medicaid Eligibility SPA Template ,   DOMA CHIP Eligibility SPA Template
#6: Medicaid Buy In Payment Suspensions	CMS-10398 (#6)	The Medicaid Buy-In Program Questionnaire
#14: MAGI Conversion Plan	CMS-10398 (#14)	Modified Adjusted Gross Income (MAGI) Conversion Plan
#25: Tobacco Cessation Quitline Expenditures	CMS-10398 (#25)	Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)
#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13)	Outpatient Hospital UPL Guidance ,   Nursing Facility UPL Guidance ,   Inpatient Hospital UPL Guidance
#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template	CMS-10398 (#7)	Reporting Template
#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412)	CMS-10398 (#38) (formerly, CMS-10412)	Section 1115 Demonstration, Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions
#24: Medicaid Accountability – Upper Payment Limits
#17 CHIP State Plan Eligibility (MACPro Templates)	CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17)	Template CS7 – Targeted Low-Income Child ,   Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Pregnant Women ,   Eligibility - Deemed Newborns ,   Eligibility - Coverage From Conception to Birth ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   General Eligibility - Eligibility Processing ,   Eligibility - Children Who Have Access to Public Employee Coverage ,   Eligibility - Pregnant Women Who Have Access to Public Employee Coverage ,   Eligibility - Dental Only Supplemental Coverage ,   Other Eligibility Criteria - Spenddowns ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Presumptive Eligibility for Children ,   Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards ,   MAGI-Based Income Methodologies ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility - Non-Payment of Premiums ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Presumptive Eligibility for Pregnant Women
#22: Health Home State Plan Amendment (SPA)	CMS-10398 (#22), CMS-10398 (#22)	Health Homes Administrative Report ,   Health Home State Plan Amendment
#7: CHIPRA Cycle II Outreach and Enrollment Grant	CMS-10398 (# 7)	CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report
#23: Medicaid Primary Care Payment Increase – State Data Collection Tool	CMS-10398 (#23)	Medicaid Primary Care Payment Increase – State Data Collection Tool
GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services	CMS-10398 (#48)	Quality Measurement Data Reporting Templates
GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews	CMS-10398 #49	Testing Protocol
GenIC #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 (Formerly CMS-R-211)	CMS-10398 #34	Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
#30: State Reporting Medicaid Payment Suspension
#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II	CMS-10398 (#3)	RACs At-A-Glance Phase II Data Collection
#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool
#19: Eligibility and Enrollment Performance Indicators	CMS-10398 (#19)	Monthly Report
#10: Section 1115 Demonstration and Waiver Application	CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10)	Long Term Services Benefit Specifications and Provider Qualifications ,   Benefit Specifications and Provider Qualifications ,   Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2 ,   Long Term Services and Supports Form ,   Budget Neutrality Form ,   Demonstration Financing Form
#20: Payment Error Rate Measurement (PERM) Pilot	CMS-10398 (#20), CMS-10398 (#20)	CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission ,   CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission
#8: (PIE) Payer Initiated Eligibility/Benefit Transaction
#12: Increase in Primary Care Services Payments	CMS-10398 (#12)	Reimbursement Template - Physician Services
#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 (CMS-R-211)	CMS-10398 (#34) (formerly, CMS-R-211)	Template for Child Health Plan Under Title XXI of the Social Security Act, Children’s Health Insurance Program
#1: CHIP Annual Report Template System (CARTs)	CMS-10398 (#1)	FRAMEWORK FOR THE ANNUAL REPORT
Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#41)	Cycle III Semi-Annual Report Template ,   Cycle IV Semi-Annual Report Template ,   Cycle III Final Report Addendum ,   1095 B Reporting (Conf Call Questions)
#28: MMIS APD Template NCCI Coding Initiative (CMS-10358)	CMS-10398 (#28)	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State’s Medicaid Management Information System (MMIS)
GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)	CMS-10398 (#43), CMS-10398 (#43)	CCMHC Cost Report ,   State Demonstration Proposal Application and Guidance
GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool	CMS-10398 (#44)	Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules
#37: Managed Care Rate Setting Guidance
#26: Medicaid Adult Core Set Measures Reporting Template in CARTS	CMS-10398 (#26)	Reporting of the Core Set of Health Care Quality Measures for Medicaid-Eligible Adults (Medicaid Adult Core Set)
#2: Medicaid Managed Care Data Collection
#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III)	CMS-10398 (#4)	RAC Phase III Reporting
#27: MAGI Conversion Plan Part 2	CMS-10398 (#27)	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	CMS-10398 (#39), CMS-10398 (#39), CMS-10398 (#40), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#39), CMS-10398 (#39), CMS-10398 (#39)	CHIPRA Cycle III - Semi-Annual Report Template ,   CHIPRA Cycle IV - Semi-Annual Report Template ,   39 Protocol for BHP States ,   39 Protocol for Coverave States ,   39 Protocol for DA States ,   39 Protocol for EI States ,   39 Protocol for FFM States ,   40 Sample Balancing Incentive Report
Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#46)	Nursing Facility UPL Guidance ,   Outpatient Hospital UPL Guidance ,   Inpatient Hospital UPL Guidance ,   Nursing Facility UPL Template ,   Outpatient Hospital UPL Template ,   Inpatient Hospital UPL Template ,   Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance ,   Clinic Upper Payment Limit (UPL) Guidance ,   Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance ,   Funding Questions ,   Medicaid Qualified Practitioner Services (Physician) Standard Template ,   Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template ,   Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template ,   Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template ,   Clinic Standard Template ,   1915(i) State Plan Home and Community-Based Services Administration and Operation
Bundle: #7 (Cycle IV and Cycle V), #37 (Managed Care Rate Setting), #50 (Community First Choice State Plan), and #52 (Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Prod	CMS-10398 (#50), CMS-10398 (#52), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7)	• Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report) ,   Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum ,   Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template ,   Cycle Vb. Connecting Kids to Coverage Final Report Template ,   Community First Choice (CFC) Template ,   Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products
Bundle: GenICs 37 (Managed Care Rate Setting Guidance), 50 (Community First Choice State Plan), and 51 (Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions)	CMS-10398 #51, CMS-10398 #51, CMS-10398 #51, CMS-10398 #50, CMS-10398 #51	#51 - 1115(f) Extension State Certification ,   Community First Choice (CFC) State Plan Option Preprint ,   #51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes ,   #51 - 1115(a) Extension State Certification ,   #51 - 1115(e) Extension State Certification
#32: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) (CMS-10364)	CMS-10398 (#32)	Pre-print Provider-Preventable Conditions
#18: Alternative Benefit Plans	CMS-10398 (#18)	Interim Form for Alternative Benefit Plans
#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	CMS-10398 (#9)	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
#37 (2016 Managed Care Rate Setting Guidance)
#11: MAGI-Based Eligibility Verification Plan	CMS-10398 (#11)	MAGI-Based Eligibility Verification Plan
#29: Medicaid Cost Sharing (CMS-R-53)	CMS-R-53	Medicaid Premiums and Cost Sharing
#33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232)	CMS-10398 (#33)	Family Opportunity Act Preprint
#21: FMAP Claiming State Plan Amendment	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates
Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45)	(Screen 1, Women) MIH Initiative Developmental Measure ,   (Screen 2, Women) MIH Initiative Developmental Measure ,   (Screen 3, Women) MIH Initiative Developmental Measure ,   (Screen 4, Women) MIH Initiative Developmental Measure ,   (Screen 5, Women) MIH Initiative Developmental Measure ,   (Screen 6, Women) MIH Initiative Developmental Measure ,   (Screen 1, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 2, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 3, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 4, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 5, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 6, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 7, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 8, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 9, Postpartum Women) MIH Initiative Developmental Measure ,   (Screen 10, Postpartum Women) MIH Initiative Developmental Measure

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,720	3,360	3,360	0	0	0
Annual Time Burden (Hours)	154,104	86,240	67,864	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/30/2014

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