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.

⚠️ Notice: This information collection may be referencing outdated material.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 7.1.17 to 6.30.18 - 03.29.2017 - clean.docx	Instruction
Medicaid Rate Guide Effective 7.1.17 to 6.30.18 - 03.29.2017 - clean (1).docx	Instruction
37 - Copy of Crosswalk for 2017-2018 Rate Guide (003).xlsx	Other-37 - Crosswalk
7 - SARComparison table_01232017 (kcl).docx	Other-7 - Crosswalk
CMS-10398 (#50) Community First Choice (CFC) Template 50 - Community First Choice template 10-14-16 CLEAN.docx	Form
CMS-10398 (#52) Section 438.6(c) - Delivery System and Provider Payment 438.6c Preprint - Clean Version_04_05_2017.docx	Form
CMS-10398 (#7) • Cycle IV AI/AN Round II Outreach & Enrollment Grant Fi 7 - Cycle IV _Part One Final_ReportingTemplate_.docx	Form and Instruction
CMS-10398 (#7) Cycle IV AI/AN Round II Outreach & Enrollment Grant Fina 7 - Cycle IV Final Report Addendum.doc	Form and Instruction
CMS-10398 (#7) Cycle Va. Connecting Kids to Coverage Semi-Annual Report 7 - Cycle Va Appendix A.1 Semiannual reporting template 2016 11 23.docx	Form and Instruction
CMS-10398 (#7) Cycle Vb. Connecting Kids to Coverage Final Report Templ 7 - Cycle Vb Final reporting template 2016 11 23 .docx	Form and Instruction
37 - Managed Care Rates Supporting Statement Final 1-10 [rev 01-25-2017 by OSORA PRA].docx 37 - Supporting Statement	IC Document
50 - Supporting Statement [rev 09-13-2016 by OSORA PRA] (3).docx 50 - Supporting Statement	IC Document
52 - Delivery System and Provider Payment Initiatives Supporting Statement 12-02-16 Final [rev 01-24-2017 by OSORA PRA].docx 52 - Supporting Statement	IC Document
7 - CHIPRA Supporting Statement Final 1-4-17 rev 01-25-2017 by kcl [rev 01-26-2017 by OSORA PRA].docx 7 - Crosswalk	IC Document
Bundled Burden Table (01-26-2017).xlsx Bundled Burden Summary Table	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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 7.1.17 to 6.30.18 - 03.29.2017 - clean.docx	No		Printable Only
Form and Instruction	CMS-10398 (#7)	â¢ 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

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: 144

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	497	497
Annual IC Time Burden (Hours)	3,192	3,192
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.