Information Collection

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)

IC 223503 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medicaid Rate Guide Effective 1.1.17 to 6.30.17 - 10.18.2016.docx	Instruction
#50 - CFC Technical Guide [rev 09-13-2016 by OSORA PRA].docx	Instruction
CMS-10398 #50 Community First Choice (CFC) State Plan Option Preprint #50 - Community First Choice template.8.31.16.docx	Form
CMS-10398 #51 #51 - Section 1115 Demonstration FAST TRACK Extension Te #51 - Extension with Changes Template_09-13-2016.doc	Form and Instruction
CMS-10398 #51 #51 - 1115(a) Extension State Certification #51 - 1115a extension state certification 09-13-2016.docx	Form and Instruction
CMS-10398 #51 #51 - 1115(e) Extension State Certification #51 - 1115e extension state certification_09-13-2016.docx	Form and Instruction
CMS-10398 #51 #51 - 1115(f) Extension State Certification #51 - 1115f extension state certification_09-13-2016.docx	Form and Instruction
#37 Supporting Statement [rev 09-13-2016 by OSORA PRA].docx #37 Supporting Stattement: Managed Care Rate Setting Guidance	IC Document
#37 - Crosswalk 2016 and 2017 Rate Guide.xlsx #37 Crosswalk: Managed Care Rate Setting Guidance	IC Document
GenIC #50 - Supporting Statement [rev 09-13-2016 by OSORA PRA].docx #50 Supporting Statement: Community First Choice State Plan	IC Document
GenIC #51 - Supporting Statement rev 09-13-2016 OSORA PRA_SDG edits 9 13 16 -- CLEAN.docx #51 Supporting Statement: Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	IC Document
Bundled Burden Table (09-13-2016).xlsx Bundled Burden Table	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Medicaid Rate Guide Effective 1.1.17 to 6.30.17 - 10.18.2016.docx	Yes	Yes	Printable Only
Form and Instruction	CMS-10398 #51	#51 - 1115(f) Extension State Certification	#51 - 1115f extension state certification_09-13-2016.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #50	Community First Choice (CFC) State Plan Option Preprint	#50 - Community First Choice template.8.31.16.docx	Yes	Yes	Fillable Fileable
Instruction			#50 - CFC Technical Guide [rev 09-13-2016 by OSORA PRA].docx	Yes	No	Printable Only
Form and Instruction	CMS-10398 #51	#51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes	#51 - Extension with Changes Template_09-13-2016.doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398 #51	#51 - 1115(a) Extension State Certification	#51 - 1115a extension state certification 09-13-2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	#51 - 1115(e) Extension State Certification	#51 - 1115e extension state certification_09-13-2016.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	113	113
Annual IC Time Burden (Hours)	1,158	1,158
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#37 Supporting Stattement: Managed Care Rate Setting Guidance	#37 Supporting Statement [rev 09-13-2016 by OSORA PRA].docx	09/13/2016
#37 Crosswalk: Managed Care Rate Setting Guidance	#37 - Crosswalk 2016 and 2017 Rate Guide.xlsx	09/13/2016
#50 Supporting Statement: Community First Choice State Plan	GenIC #50 - Supporting Statement [rev 09-13-2016 by OSORA PRA].docx	09/13/2016
#51 Supporting Statement: Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	GenIC #51 - Supporting Statement rev 09-13-2016 OSORA PRA_SDG edits 9 13 16 -- CLEAN.docx	09/13/2016
Bundled Burden Table	Bundled Burden Table (09-13-2016).xlsx	09/13/2016

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