#21: FMAP Claiming State Plan Amendment

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#21) #21: FMAP Claiming State Plan Amendment Form
FMAP Claiming SPA Instructions.docx Instruction
CMS-10398 (#21) Threshold Methodology for Identification of Applicable F FMAP Claiming SPA 9-16-13-Attachments.docx Form
#21 FMAP Claiming SPA Supporting Statement [Dec 2014].docx #21 Supporting Statement: FMAP Claiming State Plan Amendment IC Document

Information Collection (IC) Details

IC Title:	#21: FMAP Claiming State Plan Amendment	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates	FMAP Claiming SPA 9-16-13-Attachments.docx		Yes	Yes	Fillable Printable
Instruction			FMAP Claiming SPA Instructions.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#21 Supporting Statement: FMAP Claiming State Plan Amendment	#21 FMAP Claiming SPA Supporting Statement [Dec 2014].docx	12/22/2014

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