OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 225371 under ICR 201410-0938-016 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Other-37 - Crosswalk
Other-7 - Crosswalk
Form
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Medicaid Rate Guide Effective 7.1.17 to 6.30.18 - 03.29.2017 - clean.docx No   Printable Only
Form and Instruction CMS-10398 (#7) • Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report) 7 - Cycle IV _Part One Final_ReportingTemplate_.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 (#7) Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum 7 - Cycle IV Final Report Addendum.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10398 (#7) Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template 7 - Cycle Va Appendix A.1 Semiannual reporting template 2016 11 23.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 (#7) Cycle Vb. Connecting Kids to Coverage Final Report Template 7 - Cycle Vb Final reporting template 2016 11 23 .docx Yes Yes Fillable Fileable
Other-7 - Crosswalk 7 - SARComparison table_01232017 (kcl).docx No   Printable Only
Instruction Medicaid Rate Guide Effective 7.1.17 to 6.30.18 - 03.29.2017 - clean (1).docx No   Paper Only
Other-37 - Crosswalk 37 - Copy of Crosswalk for 2017-2018 Rate Guide (003).xlsx No   Paper Only
Form CMS-10398 (#50) Community First Choice (CFC) Template 50 - Community First Choice template 10-14-16 CLEAN.docx Yes Yes Fillable Fileable
Form CMS-10398 (#52) Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products 438.6c Preprint - Clean Version_04_05_2017.docx Yes Yes Fillable Fileable

Health Health Care Services

 

144 0
   
State, Local, and Tribal Governments
 
   70 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 497 0 497 0 0 0
Annual IC Time Burden (Hours) 3,192 0 3,192 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
37 - Supporting Statement 37 - Managed Care Rates Supporting Statement Final 1-10 [rev 01-25-2017 by OSORA PRA].docx 01/27/2017
50 - Supporting Statement 50 - Supporting Statement [rev 09-13-2016 by OSORA PRA] (3).docx 01/27/2017
52 - Supporting Statement 52 - Delivery System and Provider Payment Initiatives Supporting Statement 12-02-16 Final [rev 01-24-2017 by OSORA PRA].docx 01/27/2017
7 - Crosswalk 7 - CHIPRA Supporting Statement Final 1-4-17 rev 01-25-2017 by kcl [rev 01-26-2017 by OSORA PRA].docx 01/27/2017
Bundled Burden Summary Table Bundled Burden Table (01-26-2017).xlsx 01/27/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.