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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10398 #34 Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program	Form	New	Available
Form CMS-10398 (#7) Cycle Vb. Connecting Kids to Coverage Final Report Template	Form and Instruction	New	Available
Form CMS-10398 (#7) Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template	Form and Instruction	New	Available
Form CMS-10398 (#7) Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum	Form and Instruction	New	Available
Form CMS-10398 (#7) • Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)	Form and Instruction	New	Available
Form CMS-10398 (#52) Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	Form	New	Available
Form CMS-10398 (#50) Community First Choice (CFC) Template	Form	New	Available
Form CMS-10398 (#46) 1915(i) State Plan Home and Community-Based Services Administration and Operation	Form	New	Available
Form CMS-10398 (#24) Clinic Standard Template	Form and Instruction	New	Available
Form CMS-10398 (#24) Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template	Form and Instruction	New	Available
Form CMS-10398 (#24) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template	Form and Instruction	New	Available
Form CMS-10398 (#24) Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template	Form and Instruction	New	Available
Form CMS-10398 (#24) Medicaid Qualified Practitioner Services (Physician) Standard Template	Form and Instruction	New	Available
Form CMS-10398 (#24) Funding Questions	Form	New	Available
Form CMS-10398 (#24) Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance	Form	New	Available
Form CMS-10398 (#24) Clinic Upper Payment Limit (UPL) Guidance	Form	New	Available
Form CMS-10398 (#24) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance	Form	New	Available
Form CMS-10398 (#13) Inpatient Hospital UPL Template	Form and Instruction	New	Available
Form CMS-10398 (#13) Outpatient Hospital UPL Template	Form and Instruction	New	Available
Form CMS-10398 (#13) Nursing Facility UPL Template	Form and Instruction	New	Available
Form CMS-10398 (#13) Inpatient Hospital UPL Guidance	Form	New	Available
Form CMS-10398 (#13) Outpatient Hospital UPL Guidance	Form	New	Available
Form CMS-10398 (#13) Nursing Facility UPL Guidance	Form	New	Available
Form CMS-10398 #51 #51 - 1115(f) Extension State Certification	Form and Instruction	New	Available
Form CMS-10398 #51 #51 - 1115(e) Extension State Certification	Form and Instruction	New	Available
Form CMS-10398 #51 #51 - 1115(a) Extension State Certification	Form and Instruction	New	Available
Form CMS-10398 #51 #51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes	Form and Instruction	New	Available
Form CMS-10398 #50 Community First Choice (CFC) State Plan Option Preprint	Form	New	Available
Form CMS-10398 (#45) (Screen 10, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 9, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 8, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 7, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 6, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 5, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 4, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 3, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 2, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 1, Postpartum Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 6, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 5, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 4, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 3, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 2, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 (#45) (Screen 1, Women) MIH Initiative Developmental Measure	Form	New	Available
Form CMS-10398 #49 Testing Protocol	Form and Instruction	New	Available
Form CMS-10398 (#48) Quality Measurement Data Reporting Templates	Form and Instruction	New	Available
Form CMS-10398 (#43) State Demonstration Proposal Application and Guidance	Form and Instruction	New	Available
Form CMS-10398 (#43) CCMHC Cost Report	Form	New	Available
Form CMS-10398 (#44) Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules	Form and Instruction	New	Available
Form CMS-10398 (#41) 1095 B Reporting (Conf Call Questions)	Form	New	Available
Form CMS-10398 (#7) Cycle III Final Report Addendum	Form and Instruction	New	Available
Form CMS-10398 (#7) Cycle IV Semi-Annual Report Template	Form and Instruction	New	Available
Form CMS-10398 (#7) Cycle III Semi-Annual Report Template	Form and Instruction	New	Available
Form CMS-10398 (#40) 40 Sample Balancing Incentive Report	Form	New	Available
Form CMS-10398 (#39) 39 Protocol for FFM States	Form	New	Available
Form CMS-10398 (#39) 39 Protocol for EI States	Form	New	Available
Form CMS-10398 (#39) 39 Protocol for DA States	Form	New	Available
Form CMS-10398 (#39) 39 Protocol for Coverave States	Form	New	Available
Form CMS-10398 (#39) 39 Protocol for BHP States	Form	New	Available
Form CMS-10398 (#7) CHIPRA Cycle IV - Semi-Annual Report Template	Form	New	Available
Form CMS-10398 (#7) CHIPRA Cycle III - Semi-Annual Report Template	Form	New	Available
Form CMS-10398 (#35) Eligibility and Enrollment Performance Indicators Template	Form	New	Available
Form CMS-10398 (#7) Reporting Template	Form	New	Available
Form CMS-10398 (#38) (f Section 1115 Demonstration, Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions	Form and Instruction	New	Available
Form CMS-10398 (#36) DOMA CHIP Eligibility SPA Template	Form	New	Available
Form CMS-10398 (#36) DOMA Medicaid Eligibility SPA Template	Form	New	Repair queued
Form CMS-10398 (#34) (f Template for Child Health Plan Under Title XXI of the Social Security Act, Children’s Health Insurance Program	Form	New	Available
Form CMS-10398 (#33) Family Opportunity Act Preprint	Form	New	Available
Form CMS-10398 (#32) Pre-print Provider-Preventable Conditions	Form	New	Available
Form CMS-10398 (#31) Sample Template For State Settings’ Analysis	Form	New	Available
Form CMS-R-53 Medicaid Premiums and Cost Sharing	Form	New	Available
Form 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)	Form and Instruction	New	Repair queued
Form CMS-10398 (#27) Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan	Form and Instruction	New	Repair queued
Form CMS-10398 (#26) Reporting of the Core Set of Health Care Quality Measures for Medicaid-Eligible Adults (Medicaid Adult Core Set)	Form and Instruction	New	Available
Form CMS-10398 (#25) Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)	Form	New	Available
Form CMS-10398 (#23) Medicaid Primary Care Payment Increase – State Data Collection Tool	Form	New	Available
Form CMS-10398 (#22) Health Home State Plan Amendment	Form	New	Available
Form CMS-10398 (#22) Health Homes Administrative Report	Form	New	Available
Form CMS-10398 (#21) Threshold Methodology for Identification of Applicable FMAP Rates	Form	New	Available
Form CMS-10398 (#20) CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission	Form and Instruction	New	Available
Form CMS-10398 (#20) CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission	Form and Instruction	New	Available
Form CMS-10398 (#19) Monthly Report	Form	New	Available
Form CMS-10398 (#18) Interim Form for Alternative Benefit Plans	Form	New	Available
Form CMS-10398 (#17) Template CS7 – Targeted Low-Income Child	Form	New	Available
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Pregnant Women	Form	New	Available
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Children	Form	New	Available
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards	Form	New	Available
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards	Form	New	Repair queued
Form CMS-10398 (#17) Non-Financial Eligibility - Non-Payment of Premiums	Form	New	Available
Form CMS-10398 (#17) Non-Financial Eligibility - Substitution of Coverage	Form	New	Available
Form CMS-10398 (#17) Other Eligibility Criteria - Spenddowns	Form	New	Available
Form CMS-10398 (#17) Eligibility - Dental Only Supplemental Coverage	Form	New	Available
Form CMS-10398 (#17) Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CMS-10398 (#17) Eligibility - Children Who Have Access to Public Employee Coverage	Form	New	Available
Form CMS-10398 (#17) General Eligibility - Eligibility Processing	Form	New	Available
Form CMS-10398 (#17) Non-Financial Eligibility - Social Security Number	Form	New	Available
Form CMS-10398 (#17) Non-Financial Eligibility – Citizenship	Form	New	Available
Form CMS-10398 (#17) Non-Financial Eligibility – Residency	Form	New	Available
Form CMS-10398 (#17) MAGI-Based Income Methodologies	Form	New	Available
Form CMS-10398 (#17) Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	New	Available
Form CMS-10398 (#17) Eligibility - Deemed Newborns	Form	New	Repair queued
Form CMS-10398 (#17) Eligibility - Coverage From Conception to Birth	Form	New	Available
Form CMS-10398 (#17) Eligibility - Targeted Low-Income Pregnant Women	Form	New	Available
Form CMS-10398 (#17) Eligibility for Medicaid Expansion Program	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: General Eligibility Requirements Eligibility Process	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility State Residency	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents	Form	New	Repair queued
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives	Form	New	Repair queued
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals above 133% FPL	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Former Foster Care Children	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Adult Group	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Pregnant Women	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: Presumptive Eligibility by Hospitals	Form	New	Repair queued
Form CMS-10398 (#15) Medicaid Eligibility: AFDC Income Standards	Form	New	Available
Form CMS-10398 (#15) Medicaid Eligibility: MAGI-Based Income Methodologies	Form	New	Available
Form CMS-10398 (#15) Medicaid Administration: State Plan Administration/ Designation and Authority	Form	New	Available
Form CMS-10398 (#14) Modified Adjusted Gross Income (MAGI) Conversion Plan	Form and Instruction	New	Available
Form CMS-10398 (#13) Outpatient Hospital UPL Guidance	Form	New	Available
Form CMS-10398 (#13) Nursing Facility UPL Guidance	Form	New	Available
Form CMS-10398 (#13) Inpatient Hospital UPL Guidance	Form	New	Available
Form CMS-10398 (#12) Reimbursement Template - Physician Services	Form	New	Available
Form CMS-10398 (#11) MAGI-Based Eligibility Verification Plan	Form	New	Available
Form CMS-10398 (#10) Long Term Services Benefit Specifications and Provider Qualifications	Form	New	Available
Form CMS-10398 (#10) Long Term Services and Supports Form	Form and Instruction	New	Available
Form CMS-10398 (#10) Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2	Form	New	Available
Form CMS-10398 (#10) Demonstration Financing Form	Form and Instruction	New	Available
Form CMS-10398 (#10) Budget Neutrality Form	Form	New	Available
Form CMS-10398 (#10) Benefit Specifications and Provider Qualifications	Form	New	Available
Form CMS-10398 (#9) Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	Form	New	Repair queued
Form CMS-10398 (# 7) CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report	Form and Instruction	New	Available
Form CMS-10398 (#6) The Medicaid Buy-In Program Questionnaire	Form and Instruction	New	Available
Form CMS-10398 (#5) Medicaid Payment Suspensions	Form	New	Available
Form CMS-10398 (#4) RAC Phase III Reporting	Form	New	Available
Form CMS-10398 (#3) RACs At-A-Glance Phase II Data Collection	Form	New	Repair queued
Form CMS-10398 (#1) FRAMEWORK FOR THE ANNUAL REPORT	Form	New	Source copy available
Upcoming Packages 7-1-14.pdf	Supplementary Document	Uploaded 2014-10-30	Available
CMS-10398 - Supporting Statement for Generic Umbrella [rev 10-30-2014 by OSORA PRA].doc	Supporting Statement A	Uploaded 2014-10-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
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	Form and Instruction	New	Cycle Vb. Connecting Kids to Coverage Final Report Template
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	Form and Instruction	New	Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template
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	Form and Instruction	New	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
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	Form and Instruction	New	• Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)
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	Form	New	Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products
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	Form	New	Community First Choice (CFC) Template
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)	Form	New	1915(i) State Plan Home and Community-Based Services Administration and Operation
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Clinic Standard Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Medicaid Qualified Practitioner Services (Physician) Standard Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Funding Questions
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Clinic Upper Payment Limit (UPL) Guidance
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Inpatient Hospital UPL Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Outpatient Hospital UPL Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form and Instruction	New	Nursing Facility UPL Template
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Inpatient Hospital UPL Guidance
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Outpatient Hospital UPL Guidance
224389	Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)	Form	New	Nursing Facility UPL Guidance
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)	Form and Instruction	New	#51 - 1115(f) Extension State Certification
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)	Form and Instruction	New	#51 - 1115(e) Extension State Certification
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)	Form and Instruction	New	#51 - 1115(a) Extension State Certification
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)	Form and Instruction	New	#51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes
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)	Form	New	Community First Choice (CFC) State Plan Option Preprint
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)	Form	New	(Screen 10, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 9, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 8, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 7, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 6, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 5, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 4, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 3, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 2, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 1, Postpartum Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 6, Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 5, Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 4, Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 3, Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 2, Women) MIH Initiative Developmental Measure
222041	Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)	Form	New	(Screen 1, Women) MIH Initiative Developmental Measure
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	Form and Instruction	New	Testing Protocol
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	Form and Instruction	New	Quality Measurement Data Reporting Templates
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 and Instruction	New	State Demonstration Proposal Application and Guidance
219037	GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)	Form	New	CCMHC Cost Report
219037	GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)	Instruction	New
218238	GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool	Form and Instruction	New	Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules
218045	#37 (2016 Managed Care Rate Setting Guidance)	Instruction	New
217381	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	Form	New	1095 B Reporting (Conf Call Questions)
217381	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	Form and Instruction	New	Cycle III Final Report Addendum
217381	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	Form and Instruction	New	Cycle IV Semi-Annual Report Template
217381	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	Form and Instruction	New	Cycle III Semi-Annual Report Template
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	40 Sample Balancing Incentive Report
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	39 Protocol for FFM States
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	39 Protocol for EI States
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	39 Protocol for DA States
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	39 Protocol for Coverave States
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	39 Protocol for BHP States
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	CHIPRA Cycle IV - Semi-Annual Report Template
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form	New	CHIPRA Cycle III - Semi-Annual Report Template
216111	Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Other-39 State Selection Memo	New
214406	#35: Eligibility and Enrollment Performance Indicators	Form	New	Eligibility and Enrollment Performance Indicators Template
214399	#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template	Form	New	Reporting Template
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	Section 1115 Demonstration, Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions
214374	#37: Managed Care Rate Setting Guidance	Instruction	New
214373	#36: Same Sex Marriage Policy	Form	New	DOMA CHIP Eligibility SPA Template
214373	#36: Same Sex Marriage Policy	Form	New	DOMA Medicaid Eligibility SPA Template
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	Template for Child Health Plan Under Title XXI of the Social Security Act, Children’s Health Insurance Program
214371	#33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232)	Form	New	Family Opportunity Act Preprint
214365	#32: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) (CMS-10364)	Form	New	Pre-print Provider-Preventable Conditions
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	Form	New	Sample Template For State Settings’ Analysis
214359	#31: Statewide HCBS Transition Plans	Instruction	New
214342	#29: Medicaid Cost Sharing (CMS-R-53)	Form	New	Medicaid Premiums and Cost Sharing
214342	#29: Medicaid Cost Sharing (CMS-R-53)	Instruction	New
214338	#28: MMIS APD Template NCCI Coding Initiative (CMS-10358)	Form and Instruction	New	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State’s Medicaid Management Information System (MMIS)
214334	#27: MAGI Conversion Plan Part 2	Form and Instruction	New	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
214332	#26: Medicaid Adult Core Set Measures Reporting Template in CARTS	Form and Instruction	New	Reporting of the Core Set of Health Care Quality Measures for Medicaid-Eligible Adults (Medicaid Adult Core Set)
214331	#25: Tobacco Cessation Quitline Expenditures	Form	New	Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)
214330	#23: Medicaid Primary Care Payment Increase – State Data Collection Tool	Form	New	Medicaid Primary Care Payment Increase – State Data Collection Tool
214329	#24: Medicaid Accountability – Upper Payment Limits	Instruction	New
214328	#22: Health Home State Plan Amendment (SPA)	Form	New	Health Home State Plan Amendment
214328	#22: Health Home State Plan Amendment (SPA)	Form	New	Health Homes Administrative Report
214322	#21: FMAP Claiming State Plan Amendment	Form	New	Threshold Methodology for Identification of Applicable FMAP Rates
214322	#21: FMAP Claiming State Plan Amendment	Instruction	New
214321	#20: Payment Error Rate Measurement (PERM) Pilot	Form and Instruction	New	CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission
214321	#20: Payment Error Rate Measurement (PERM) Pilot	Form and Instruction	New	CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission
214321	#20: Payment Error Rate Measurement (PERM) Pilot	Other-SHO Letter	New
214320	#19: Eligibility and Enrollment Performance Indicators	Form	New	Monthly Report
214319	#18: Alternative Benefit Plans	Form	New	Interim Form for Alternative Benefit Plans
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Template CS7 – Targeted Low-Income Child
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	General Eligibility - Presumptive Eligibility for Pregnant Women
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	General Eligibility - Presumptive Eligibility for Children
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Requirements - Other Eligibility Standards
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Requirements - Other Eligibility Standards
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Eligibility - Non-Payment of Premiums
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Eligibility - Substitution of Coverage
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Other Eligibility Criteria - Spenddowns
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Dental Only Supplemental Coverage
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Children Who Have Access to Public Employee Coverage
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	General Eligibility - Eligibility Processing
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Eligibility - Social Security Number
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Eligibility – Citizenship
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Non-Financial Eligibility – Residency
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	MAGI-Based Income Methodologies
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Deemed Newborns
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Coverage From Conception to Birth
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility - Targeted Low-Income Pregnant Women
214318	#17 CHIP State Plan Eligibility (MACPro Templates)	Form	New	Eligibility for Medicaid Expansion Program
214317	#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool	Instruction	New
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: General Eligibility Requirements Eligibility Process
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Non-Financial Eligibility State Residency
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Mandatory Coverage Adult Group
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Mandatory Coverage Pregnant Women
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: Presumptive Eligibility by Hospitals
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: AFDC Income Standards
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Eligibility: MAGI-Based Income Methodologies
214314	#15: Medicaid State Plan Eligibility	Form	New	Medicaid Administration: State Plan Administration/ Designation and Authority
214301	#14: MAGI Conversion Plan	Form and Instruction	New	Modified Adjusted Gross Income (MAGI) Conversion Plan
214296	#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Outpatient Hospital UPL Guidance
214296	#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Nursing Facility UPL Guidance
214296	#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Inpatient Hospital UPL Guidance
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	Reimbursement Template - Physician Services
214294	#11: MAGI-Based Eligibility Verification Plan	Form	New	MAGI-Based Eligibility Verification Plan
214293	#10: Section 1115 Demonstration and Waiver Application	Form	New	Long Term Services Benefit Specifications and Provider Qualifications
214293	#10: Section 1115 Demonstration and Waiver Application	Form and Instruction	New	Long Term Services and Supports Form
214293	#10: Section 1115 Demonstration and Waiver Application	Form	New	Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2
214293	#10: Section 1115 Demonstration and Waiver Application	Form and Instruction	New	Demonstration Financing Form
214293	#10: Section 1115 Demonstration and Waiver Application	Form	New	Budget Neutrality Form
214293	#10: Section 1115 Demonstration and Waiver Application	Form	New	Benefit Specifications and Provider Qualifications
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	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
214287	#8: (PIE) Payer Initiated Eligibility/Benefit Transaction	Instruction	New
214286	#7: CHIPRA Cycle II Outreach and Enrollment Grant	Form and Instruction	New	CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report
214285	#6: Medicaid Buy In Payment Suspensions	Form and Instruction	New	The Medicaid Buy-In Program Questionnaire
214283	#5: Medicaid Payment Suspensions	Form	New	Medicaid Payment Suspensions
214276	#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III)	Form	New	RAC Phase III Reporting
214256	#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II	Form	New	RACs At-A-Glance Phase II Data Collection
214255	#2: Medicaid Managed Care Data Collection	Instruction	New
214252	#1: CHIP Annual Report Template System (CARTs)	Form	New	FRAMEWORK FOR THE ANNUAL REPORT

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
Retrieve Notice of Action (NOA)	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.

table that charts list comparision

	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
   Statute at Large: 19 Stat. 1901
   Statute at Large: 21 Stat. 2101
   Statute at Large: 19 Stat. 1915
  

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

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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

table that charts list of burden

IC Title	Form No.	Form Name
#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)	Benefit Specifications and Provider Qualifications ,   Budget Neutrality Form ,   Demonstration Financing Form ,   Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2 ,   Long Term Services and Supports Form ,   Long Term Services Benefit Specifications and Provider Qualifications
#11: MAGI-Based Eligibility Verification Plan	CMS-10398 (#11)	MAGI-Based Eligibility Verification Plan
#12: Increase in Primary Care Services Payments	CMS-10398 (#12)	Reimbursement Template - Physician Services
#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13)	Inpatient Hospital UPL Guidance ,   Nursing Facility UPL Guidance ,   Outpatient Hospital UPL Guidance
#14: MAGI Conversion Plan	CMS-10398 (#14)	Modified Adjusted Gross Income (MAGI) Conversion Plan
#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 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 Individuals above 133% FPL ,   Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives ,   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: 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 ,   Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility ,   Medicaid Eligibility: General Eligibility Requirements Eligibility Process
#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool
#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)	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Pregnant Women ,   Eligibility - Coverage From Conception to Birth ,   Eligibility - Deemed Newborns ,   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 – 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 Eligibility - Non-Payment of Premiums ,   Non-Financial Requirements - Other Eligibility Standards ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Presumptive Eligibility for Children ,   General Eligibility - Presumptive Eligibility for Pregnant Women ,   Template CS7 – Targeted Low-Income Child
#18: Alternative Benefit Plans	CMS-10398 (#18)	Interim Form for Alternative Benefit Plans
#19: Eligibility and Enrollment Performance Indicators	CMS-10398 (#19)	Monthly Report
#1: CHIP Annual Report Template System (CARTs)	CMS-10398 (#1)	FRAMEWORK FOR THE ANNUAL REPORT
#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
#21: FMAP Claiming State Plan Amendment	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates
#22: Health Home State Plan Amendment (SPA)	CMS-10398 (#22), CMS-10398 (#22)	Health Homes Administrative Report ,   Health Home State Plan Amendment
#23: Medicaid Primary Care Payment Increase – State Data Collection Tool	CMS-10398 (#23)	Medicaid Primary Care Payment Increase – State Data Collection Tool
#24: Medicaid Accountability – Upper Payment Limits
#25: Tobacco Cessation Quitline Expenditures	CMS-10398 (#25)	Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)
#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)
#27: MAGI Conversion Plan Part 2	CMS-10398 (#27)	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
#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)
#29: Medicaid Cost Sharing (CMS-R-53)	CMS-R-53	Medicaid Premiums and Cost Sharing
#2: Medicaid Managed Care Data Collection
#30: State Reporting Medicaid Payment Suspension
#31: Statewide HCBS Transition Plans	CMS-10398 (#31)	Sample Template For State Settings’ Analysis
#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
#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
#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
#35: Eligibility and Enrollment Performance Indicators	CMS-10398 (#35)	Eligibility and Enrollment Performance Indicators Template
#36: Same Sex Marriage Policy	CMS-10398 (#36), CMS-10398 (#36)	DOMA Medicaid Eligibility SPA Template ,   DOMA CHIP Eligibility SPA Template
#37 (2016 Managed Care Rate Setting Guidance)
#37: Managed Care Rate Setting Guidance
#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
#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II	CMS-10398 (#3)	RACs At-A-Glance Phase II Data Collection
#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III)	CMS-10398 (#4)	RAC Phase III Reporting
#5: Medicaid Payment Suspensions	CMS-10398 (#5)	Medicaid Payment Suspensions
#6: Medicaid Buy In Payment Suspensions	CMS-10398 (#6)	The Medicaid Buy-In Program Questionnaire
#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template	CMS-10398 (#7)	Reporting Template
#7: CHIPRA Cycle II Outreach and Enrollment Grant	CMS-10398 (# 7)	CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report
#8: (PIE) Payer Initiated Eligibility/Benefit Transaction
#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
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: #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
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)
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: #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)	Community First Choice (CFC) Template ,   Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products ,   • 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
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	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 ,   #51 - 1115(f) Extension State Certification
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 #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
GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool	CMS-10398 (#44)	Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules
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

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ICR Summary of Burden

table that charts list 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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