Medicaid and CHIP Program (MACPro) (CMS-10434)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10434 #45 MIHQM2017-CCW	Form	New	Available
Form CMS-10434 #45 MIHQM2017-AdminScreen	Form	New	Available
Form CMS-10434 #26 CQM2018-WCC-CH	Form	New	Repair queued
Form CMS-10434 #26 CQM2018-W34-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-W15-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-SEAL-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-PPC-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-PDENT-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-PC02-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-LBW-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-IMA-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-FUH-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-DEV-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CPC-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CLABSI-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CIS-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CHL-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CDF-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CCW-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CCP-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-CAP-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-AWC-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-AUD-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-APP-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-APC-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-AMR-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-AMB-CH	Form	New	Available
Form CMS-10434 #26 CQM2018-AdminScreen	Form	New	Available
Form CMS-10434 #26 CQM2018-ADD-CH	Form	New	Available
Form CMS-10434 #26 CQM2017-WCC	Form	New	Available
Form CMS-10434 #26 CQM2017-W34	Form	New	Available
Form CMS-10434 #26 CQM2017-W15	Form	New	Available
Form CMS-10434 #26 CQM2017-StateSpecific	Form	New	Available
Form CMS-10434 #26 CQM2017-SRA	Form	New	Available
Form CMS-10434 #26 CQM2017-SEAL	Form	New	Available
Form CMS-10434 #26 CQM2017-PPC	Form	New	Available
Form CMS-10434 #26 CQM2017-PDENT	Form	New	Available
Form CMS-10434 #26 CQM2017-PC02	Form	New	Available
Form CMS-10434 #26 CQM2017-MMA	Form	New	Available
Form CMS-10434 #26 CQM2017-LBW	Form	New	Available
Form CMS-10434 #26 CQM2017-IMA	Form	New	Available
Form CMS-10434 #26 CQM2017-FUH	Form	New	Available
Form CMS-10434 #26 CQM2017-FPC	Form	New	Available
Form CMS-10434 #26 CQM2017-DEV	Form	New	Available
Form CMS-10434 #26 CQM2017-CPC	Form	New	Available
Form CMS-10434 #26 CQM2017-CLABSI	Form	New	Available
Form CMS-10434 #26 CQM2017-CIS	Form	New	Available
Form CMS-10434 #26 CQM2017-CHL	Form	New	Available
Form CMS-10434 #26 CQM2017-CAP	Form	New	Available
Form CMS-10434 #26 CQM2017-BHRA	Form	New	Available
Form CMS-10434 #26 CQM2017-AWC	Form	New	Available
Form CMS-10434 #26 CQM2017-AUD	Form	New	Available
Form CMS-10434 #26 CQM2017-APP	Form	New	Available
Form CMS-10434 #26 CQM2017-APC	Form	New	Available
Form CMS-10434 #26 CQM2017-AMB	Form	New	Available
Form CMS-10434 #26 CQM2017-AdminScreen	Form	New	Available
Form CMS-10434 #26 CQM2017-ADD	Form	New	Available
Form CMS-10434 #26 AQM2018-SSD AD	Form	New	Available
Form CMS-10434 #26 AQM2018-SSA AD	Form	New	Available
Form CMS-10434 #26 AQM2018-PQI15	Form	New	Available
Form CMS-10434 #26 AQM2018-PQI08	Form	New	Available
Form CMS-10434 #26 AQM2018-PQI05	Form	New	Available
Form CMS-10434 #26 AQM2018-PQI01	Form	New	Available
Form CMS-10434 #26 AQM2018-PPC AD	Form	New	Available
Form CMS-10434 #26 AQM2018-PCR AD	Form	New	Available
Form CMS-10434 #26 AQM2018-PC03 AD	Form	New	Available
Form CMS-10434 #26 AQM2018-PC01 AD	Form	New	Available
Form CMS-10434 #26 AQM2018-OHD	Form	New	Available
Form CMS-10434 #26 AQM2018-MSC	Form	New	Available
Form CMS-10434 #26 AQM2018-MPM AD	Form	New	Available
Form CMS-10434 #26 AQM2018-IET	Form	New	Available
Form CMS-10434 #26 AQM2018-HVL	Form	New	Available
Form CMS-10434 #26 AQM2018-HPCMI	Form	New	Available
Form CMS-10434 #26 AQM2018-HPC	Form	New	Available
Form CMS-10434 #26 AQM2018-HA1C	Form	New	Available
Form CMS-10434 #26 AQM2018-FVA	Form	New	Available
Form CMS-10434 #26 AQM2018-FUH	Form	New	Available
Form CMS-10434 #26 AQM2018-FUA FUM	Form	New	Available
Form CMS-10434 #26 AQM2018-CPA	Form	New	Available
Form CMS-10434 #26 AQM2018-COB	Form	New	Available
Form CMS-10434 #26 AQM2018-CHL	Form	New	Available
Form CMS-10434 #26 AQM2018-CCW	Form	New	Available
Form CMS-10434 #26 AQM2018-CCS	Form	New	Available
Form CMS-10434 #26 AQM2018-CCP	Form	New	Available
Form CMS-10434 #26 AQM2018-CBP	Form	New	Available
Form CMS-10434 #26 AQM2018-BCS	Form	New	Available
Form CMS-10434 #26 AQM2018-AMR	Form	New	Available
Form CMS-10434 #26 AQM2018-AMM	Form	New	Available
Form CMS-10434 #26 AQM2018-AdminScreen	Form	New	Available
Form CMS-10434 #26 AQM2018-ABA	Form	New	Available
Form CMS-10434 #26 AQM2017-SSD	Form	New	Available
Form CMS-10434 #26 AQM2017-SAA	Form	New	Available
Form CMS-10434 #26 AQM2017-PQI15	Form	New	Available
Form CMS-10434 #26 AQM2017-PQI08	Form	New	Available
Form CMS-10434 #26 AQM2017-PQI05	Form	New	Available
Form CMS-10434 #26 AQM2017-PQI01	Form	New	Available
Form CMS-10434 #26 AQM2017-PPC	Form	New	Available
Form CMS-10434 #26 AQM2017-PCR	Form	New	Available
Form CMS-10434 #26 AQM2017-PC03	Form	New	Available
Form CMS-10434 #26 AQM2017-PCO1	Form	New	Available
Form CMS-10434 #26 AQM2017-OHD	Form	New	Available
Form CMS-10434 #26 AQM2017-MSC	Form	New	Available
Form CMS-10434 #26 AQM2017-MPM	Form	New	Available
Form CMS-10434 #26 AQM2017-IET	Form	New	Available
Form CMS-10434 #26 AQM2017-HVL	Form	New	Available
Form CMS-10434 #26 AQM2017-HPCMI	Form	New	Available
Form CMS-10434 #26 AQM2017-HPC	Form	New	Available
Form CMS-10434 #26 AQM2017-HA1C	Form	New	Available
Form CMS-10434 #26 AQM2017-FVA	Form	New	Available
Form CMS-10434 #26 AQM2017-FUH	Form	New	Available
Form CMS-10434 #26 AQM2017-FUA	Form	New	Available
Form CMS-10434 #26 AQM2017-CPA	Form	New	Available
Form CMS-10434 #26 AQM2017-CHL	Form	New	Available
Form CMS-10434 #26 AQM2017-CDF	Form	New	Available
Form CMS-10434 #26 AQM2017-CCS	Form	New	Available
Form CMS-10434 #26 AQM2017-CCP	Form	New	Available
Form CMS-10434 #26 AQM2017-CBP	Form	New	Available
Form CMS-10434 #26 AQM2017-BCS	Form	New	Available
Form CMS-10434 #26 AQM2017-AMM	Form	New	Available
Form CMS-10434 #26 AQM2017-AdminScreen	Form	New	Available
Form CMS-10434 #26 AQM2017-ABA	Form	New	Available
Form 1 Application	Form and Instruction	New	Available
Form 1 Eligibility Process	Form and Instruction	New	Available
Form 1 Citizenship and Non-Citizenship	Form and Instruction	New	Available
Form 1 State Residency	Form and Instruction	New	Available
Form 1 Individuals Eligible for Family Planning Services - Presumptive Eligibility	Form and Instruction	New	Available
Form 1 Individuals Eligible for Family Planning Services	Form and Instruction	New	Available
Form 1 Independent Foster Care Adolescents	Form and Instruction	New	Available
Form 1 Individuals with Tuberculosis	Form and Instruction	New	Available
Form 1 Optional Targeted Low Income Children	Form and Instruction	New	Repair queued
Form 1 Children with Non IV-E Adoption Assistance	Form and Instruction	New	Available
Form 1 Reasonable Classification of Individuals under Age 21	Form and Instruction	New	Available
Form 1 Optional Coverage of Parents and Other Caretaker Relatives	Form and Instruction	New	Available
Form 1 Individuals above 133% FPL under Age 65 - Presumptive Eligibility	Form and Instruction	New	Available
Form 1 Individuals above 133% FPL under Age 65	Form and Instruction	New	Available
Form 1 Mandatory Eligibility Groups	Form and Instruction	New	Available
Form 1 De-selected	Form and Instruction	New	Available
Form 1 Former Foster Care Children – Presumptive Eligibility	Form and Instruction	New	Available
Form 1 Former Foster Care Children	Form and Instruction	New	Available
Form 1 Adult Group - Presumptive Eligibility – Territories	Form and Instruction	New	Available
Form 1 Adult Group - Presumptive Eligibility	Form and Instruction	New	Available
Form 1 Adult Group	Form and Instruction	New	Available
Form 1 Infants and Children under Age 19 – Territories	Form and Instruction	New	Available
Form 1 Infants and Children under Age 19	Form and Instruction	New	Available
Form 1 Optional Eligibility Groups	Form and Instruction	New	Available
Form 1 Financial Eligibility Requirements for Non-MAGI Groups – Territories	Form and Instruction	New	Available
Form 1 Presumptive Eligibility for Pregnant Women	Form and Instruction	New	Available
Form 1 Presumptive Eligibility for Pregnant Women	Form and Instruction	New	Available
Form 1 Pregnant Women	Form and Instruction	New	Available
Form 1 Presumptive Eligibility for Parents and Other Caretaker Relatives	Form and Instruction	New	Available
Form 1 Parents and Other Caretaker Relatives	Form and Instruction	New	Available
Form 1 Presumptive Eligibility by Hospitals	Form and Instruction	New	Available
Form 1 Financial Eligibility Requirements for Non-MAGI Groups	Form and Instruction	New	Available
Form 1 Qualified Entities	Form and Instruction	New	Available
Form 1 Presumptive Eligibility for Children under Age 19	Form and Instruction	New	Available
Form 1 Income Standards - AFDC-related – Territories	Form and Instruction	New	Available
Form 1 Income Standards – Poverty Level – Territories	Form and Instruction	New	Available
Form 1 AFDC Income Standards	Form and Instruction	New	Available
Form 1 Income Standard	Form and Instruction	New	Available
Form 1 Reasonable Classification of Children Limit	Form and Instruction	New	Available
Form 1 Reasonable Classification of Children All	Form and Instruction	New	Repair queued
Form 1 MAGI Based Methodologies – Territories	Form and Instruction	New	Available
Form 1 MAGI Based Methodologies	Form and Instruction	New	Repair queued
Form 1 Other Comment	Form and Instruction	New	Available
Form 1 Public Comment	Form and Instruction	New	Available
Form 1 Medicaid State Plan	Form and Instruction	New	Available
Form 1 Submission Summary	Form and Instruction	New	Available
Form 1 Single State Agency Assurances	Form and Instruction	New	Available
Form CMS-10434 #15 Organization and Administration	Form and Instruction	New	Available
Form CMS-10434 #15 Eligibility Determinations and Fair Hearings	Form and Instruction	New	Available
Form CMS-10434 #15 Intergovernmental Cooperation Act Waivers	Form and Instruction	New	Available
Form CMS-10434 #15 Designation and Authority	Form and Instruction	New	Available
Form 1 Tribal Input	Form and Instruction	New	Available
Form HHQM21 Technical-Assistance	Form	New	Available
Form HHQM20 If-Data-Not-Reported	Form	New	Available
Form HHQM19 Hybrid-or-EHR	Form	New	Available
Form HHQM18 Hybrid-Data-Source	Form	New	Available
Form HHQM17 HHQM-SSGM	Form	New	Available
Form HHQM16 HHQM-PQI92	Form	New	Available
Form HHQM15 HHQM-PCR	Form	New	Available
Form HHQM13 HHQM-IU	Form	New	Available
Form HHQM12 HHQM-IET	Form	New	Available
Form HHQM11 HHQM-FUH	Form	New	Available
Form HHQM10 HHQM-CTR	Form	New	Available
Form HHQM9 HHQM-CDF	Form	New	Available
Form HHQM8 HHQM-CBP	Form	New	Available
Form HHQM7 HHQM-AMB	Form	New	Available
Form HHQM6 HHQM-ABA	Form	New	Available
Form HHQM5 Admin-Combined-Rates	Form	New	Available
Form HHQM4 Admin-Screen	Form	New	Available
Form HHQM3 Admin-Questions	Form	New	Available
Form HHQM2 Admin-Hybrid-Data-Source	Form	New	Available
Form HHQM1 Admin-Data-Source	Form	New	Available
Form HHQM14 HHQM-NFU	Form	New	Available
Form CMS-10434 #22 Other Comment – Screenshots	Form	New	Available
Form CMS-10434 #22 Tribal Input – Screenshots	Form	New	Available
Form CMS-10434 #22 Public Comment – Screenshots	Form	New	Available
Form CMS-10434 #22 Medicaid State Plan – Screenshots	Form	New	Available
Form CMS-10398 #22 Submission Summary – Screenshots	Form	New	Repair queued
Form CMS-10434 #22 Health Homes Program Termination – Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Payment Methodologies – Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Service Delivery Systems – Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Providers Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Services Screenshots	Form	New	Available
Form CMS-10434 #22 Geographic Limitations Screenshots	Form	New	Available
Form CMS-10434 #22 Population and Enrollment Screenshots	Form	New	Available
Form CMS-10434 #22 Health Homes Intro Screenshots	Form	New	Repair queued
Form CMS-10434 (#3) GenIC #3 - Screen Shots (Alternative Benefit Plans)	Form	Unchanged	Available
Form CMS-10434 (#2) CHIP Eligibility	Form	Unchanged	Repair queued
Form CMS-10434 (#2) CHIP Admin	Form	Unchanged	Repair queued
Form CMS-10434 (#1) MACPro Homepage	Form	Modified	Available
Form CMS-10434 (#1) Initial Application (SPA Administration)	Form	Modified	Available
Form CMS-10434 (#1) Initial Application	Form	Modified	Available
Justification for Nonsubstantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-08-03	Available
CMS-10434 - Supporting Statement A [rev 03-28-2016 by OSORA PRA].docx	Supporting Statement A	Uploaded 2016-03-30	Available
MACPro PRA Hours Used and Upcoming Packages 03-22-16.xlsx	Supplementary Document	Uploaded 2016-03-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
236830	GenIC # 45 (Transfer from 0938-1148): Maternal and Infant Health Quality	Form	New	MIHQM2017-CCW
236830	GenIC # 45 (Transfer from 0938-1148): Maternal and Infant Health Quality	Form	New	MIHQM2017-AdminScreen
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Instruction	New
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-WCC-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-W34-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-W15-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-SEAL-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-PPC-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-PDENT-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-PC02-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-LBW-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-IMA-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-FUH-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-DEV-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CPC-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CLABSI-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CIS-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CHL-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CDF-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CCW-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CCP-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-CAP-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-AWC-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-AUD-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-APP-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-APC-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-AMR-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-AMB-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-AdminScreen
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2018-ADD-CH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-WCC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-W34
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-W15
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-StateSpecific
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-SRA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-SEAL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-PPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-PDENT
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-PC02
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-MMA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-LBW
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-IMA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-FUH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-FPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-DEV
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-CPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-CLABSI
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-CIS
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-CHL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-CAP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-BHRA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-AWC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-AUD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-APP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-APC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-AMB
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-AdminScreen
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	CQM2017-ADD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-SSD AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-SSA AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PQI15
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PQI08
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PQI05
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PQI01
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PPC AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PCR AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PC03 AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-PC01 AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-OHD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-MSC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-MPM AD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-IET
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-HVL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-HPCMI
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-HPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-HA1C
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-FVA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-FUH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-FUA FUM
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CPA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-COB
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CHL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CCW
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CCS
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CCP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-CBP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-BCS
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-AMR
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-AMM
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-AdminScreen
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2018-ABA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-SSD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-SAA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PQI15
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PQI08
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PQI05
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PQI01
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PCR
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PC03
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-PCO1
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-OHD
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-MSC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-MPM
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-IET
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-HVL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-HPCMI
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-HPC
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-HA1C
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-FVA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-FUH
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-FUA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CPA
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CHL
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CDF
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CCS
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CCP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-CBP
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-BCS
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-AMM
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-AdminScreen
236825	GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form	New	AQM2017-ABA
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Application
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Eligibility Process
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Citizenship and Non-Citizenship
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	State Residency
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Individuals Eligible for Family Planning Services - Presumptive Eligibility
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Individuals Eligible for Family Planning Services
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Independent Foster Care Adolescents
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Individuals with Tuberculosis
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Optional Targeted Low Income Children
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Children with Non IV-E Adoption Assistance
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Reasonable Classification of Individuals under Age 21
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Optional Coverage of Parents and Other Caretaker Relatives
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Individuals above 133% FPL under Age 65 - Presumptive Eligibility
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Individuals above 133% FPL under Age 65
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Mandatory Eligibility Groups
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	De-selected
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Former Foster Care Children – Presumptive Eligibility
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Former Foster Care Children
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Adult Group - Presumptive Eligibility – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Adult Group - Presumptive Eligibility
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Adult Group
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Infants and Children under Age 19 – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Infants and Children under Age 19
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Optional Eligibility Groups
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Financial Eligibility Requirements for Non-MAGI Groups – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Presumptive Eligibility for Pregnant Women
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Presumptive Eligibility for Pregnant Women
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Pregnant Women
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Presumptive Eligibility for Parents and Other Caretaker Relatives
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Parents and Other Caretaker Relatives
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Presumptive Eligibility by Hospitals
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Financial Eligibility Requirements for Non-MAGI Groups
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Qualified Entities
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Presumptive Eligibility for Children under Age 19
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Income Standards - AFDC-related – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Income Standards – Poverty Level – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	AFDC Income Standards
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Income Standard
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Reasonable Classification of Children Limit
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Reasonable Classification of Children All
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	MAGI Based Methodologies – Territories
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	MAGI Based Methodologies
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Other Comment
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Public Comment
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Medicaid State Plan
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Submission Summary
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Single State Agency Assurances
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Organization and Administration
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Eligibility Determinations and Fair Hearings
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Intergovernmental Cooperation Act Waivers
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Designation and Authority
236741	GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction	New	Tribal Input
235671	GenIC #47 - Health Home Core Sets	Form	New	Technical-Assistance
235671	GenIC #47 - Health Home Core Sets	Form	New	If-Data-Not-Reported
235671	GenIC #47 - Health Home Core Sets	Form	New	Hybrid-or-EHR
235671	GenIC #47 - Health Home Core Sets	Form	New	Hybrid-Data-Source
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-SSGM
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-PQI92
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-PCR
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-IU
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-IET
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-FUH
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-CTR
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-CDF
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-CBP
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-AMB
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-ABA
235671	GenIC #47 - Health Home Core Sets	Form	New	Admin-Combined-Rates
235671	GenIC #47 - Health Home Core Sets	Form	New	Admin-Screen
235671	GenIC #47 - Health Home Core Sets	Form	New	Admin-Questions
235671	GenIC #47 - Health Home Core Sets	Form	New	Admin-Hybrid-Data-Source
235671	GenIC #47 - Health Home Core Sets	Form	New	Admin-Data-Source
235671	GenIC #47 - Health Home Core Sets	Form	New	HHQM-NFU
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Other-SMDL Letter	New
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Other Comment – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Tribal Input – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Public Comment – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Medicaid State Plan – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Submission Summary – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Program Termination – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Payment Methodologies – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Service Delivery Systems – Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Providers Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Services Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Geographic Limitations Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Population and Enrollment Screenshots
235263	GenIC #22 - Health Home State Plan Amendment (SPA)	Form	New	Health Homes Intro Screenshots
220810	GenIC #3 - Alternative Benefit Plans (ABPs)	Form	Unchanged	GenIC #3 - Screen Shots (Alternative Benefit Plans)
220809	GenIC #2 - CHIP State Plan Eligibility	Instruction	Unchanged
220809	GenIC #2 - CHIP State Plan Eligibility	Form	Unchanged	CHIP Eligibility
220809	GenIC #2 - CHIP State Plan Eligibility	Form	Unchanged	CHIP Admin
220807	GenIC #1 - Initial Application	Instruction	Modified
220807	GenIC #1 - Initial Application	Form	Modified	MACPro Homepage
220807	GenIC #1 - Initial Application	Form	Modified	Initial Application (SPA Administration)
220807	GenIC #1 - Initial Application	Form	Modified	Initial Application

ICR Details

OMB Control No: 0938-1188	ICR Reference No: 201708-0938-004
Status: Historical Active	Previous ICR Reference No: 201603-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Medicaid and CHIP Program (MACPro) (CMS-10434)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/07/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/03/2017
Terms of Clearance: Approved with the understanding that some of the burden hours are also captured under 0938-1148. in order to avoid double-counting, the burden hours associated with 0938-1148 should be reassessed periodically and eliminated as they are accounted for under this ICR.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	08/31/2019	08/31/2019
Responses	280	0	280
Time Burden (Hours)	96,844	0	2,772
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is in the process of evaluating Medicaid systems currently operating, in order to build an enterprise architecture platform and data repository. Ideally, CMS would allow for a single point of entry to access various program and operational data applications. This effort will be implemented in phases over several years. Phase 1 will provide for a Medicaid and CHIP Program data system (MACPro) accessed through a web portal/portlet that will automate the input and retrieval of data from the states related to CHIP eligibility and Alternative Benchmark Plans (ABP). This system will also support an efficient workflow for the review and approval of the CHIP and ABP process. States will access this system and submit program information into structured data templates. CMS staff will review the templates for compliance with federal statute, regulation and policy, provide feedback to the states and track/monitor the review and approval process. Future project phasing will provide for the design, delivery and implementation of financial management programs and performance and quality metrics. CMS must meet a hard deadline for the implementation of the Affordable Care Act. This system will be operational in phases with the CHIP eligibility and benchmark plans portions/modules to be implemented in January 2013.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1103 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1103 Name of Law: Patient Protection and Affordable Care Act

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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:
	80 FR 69227	11/09/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 17167	03/28/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
GenIC #3 - Alternative Benefit Plans (ABPs)	CMS-10434 (#3)	GenIC #3 - Screen Shots (Alternative Benefit Plans)
GenIC # 45 (Transfer from 0938-1148): Maternal and Infant Health Quality	CMS-10434 #45, CMS-10434 #45	MIHQM2017-AdminScreen ,   MIHQM2017-CCW
GenIC #1 - Initial Application	CMS-10434 (#1), CMS-10434 (#1), CMS-10434 (#1)	Initial Application ,   Initial Application (SPA Administration) ,   MACPro Homepage
GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, CMS-10434 #15, 1, 1, 1, 1, 1, CMS-10434 #15, CMS-10434 #15, CMS-10434 #15, 1, 1, 1, 1	Designation and Authority ,   Intergovernmental Cooperation Act Waivers ,   Eligibility Determinations and Fair Hearings ,   Organization and Administration ,   Single State Agency Assurances ,   Submission Summary ,   Medicaid State Plan ,   Public Comment ,   Tribal Input ,   Other Comment ,   MAGI Based Methodologies ,   MAGI Based Methodologies – Territories ,   Reasonable Classification of Children All ,   Reasonable Classification of Children Limit ,   Income Standard ,   AFDC Income Standards ,   Income Standards – Poverty Level – Territories ,   Income Standards - AFDC-related – Territories ,   Presumptive Eligibility for Children under Age 19 ,   Qualified Entities ,   Financial Eligibility Requirements for Non-MAGI Groups ,   Presumptive Eligibility by Hospitals ,   Parents and Other Caretaker Relatives ,   Presumptive Eligibility for Parents and Other Caretaker Relatives ,   Pregnant Women ,   Presumptive Eligibility for Pregnant Women ,   Presumptive Eligibility for Pregnant Women ,   Financial Eligibility Requirements for Non-MAGI Groups – Territories ,   Optional Eligibility Groups ,   Infants and Children under Age 19 ,   Infants and Children under Age 19 – Territories ,   Adult Group ,   Adult Group - Presumptive Eligibility ,   Adult Group - Presumptive Eligibility – Territories ,   Former Foster Care Children ,   Former Foster Care Children – Presumptive Eligibility ,   De-selected ,   Mandatory Eligibility Groups ,   Individuals above 133% FPL under Age 65 ,   Individuals above 133% FPL under Age 65 - Presumptive Eligibility ,   Optional Coverage of Parents and Other Caretaker Relatives ,   Reasonable Classification of Individuals under Age 21 ,   Children with Non IV-E Adoption Assistance ,   Optional Targeted Low Income Children ,   Individuals with Tuberculosis ,   Independent Foster Care Adolescents ,   Individuals Eligible for Family Planning Services ,   Individuals Eligible for Family Planning Services - Presumptive Eligibility ,   State Residency ,   Citizenship and Non-Citizenship ,   Eligibility Process ,   Application
GenIC #2 - CHIP State Plan Eligibility	CMS-10434 (#2), CMS-10434 (#2)	CHIP Admin ,   CHIP Eligibility
GenIC #22 - Health Home State Plan Amendment (SPA)	CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22, CMS-10398 #22, CMS-10434 #22, CMS-10434 #22, CMS-10434 #22	Health Homes Intro Screenshots ,   Population and Enrollment Screenshots ,   Geographic Limitations Screenshots ,   Health Homes Services Screenshots ,   Health Homes Providers Screenshots ,   Health Homes Service Delivery Systems – Screenshots ,   Health Homes Payment Methodologies – Screenshots ,   Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots ,   Health Homes Program Termination – Screenshots ,   Submission Summary – Screenshots ,   Medicaid State Plan – Screenshots ,   Public Comment – Screenshots ,   Tribal Input – Screenshots ,   Other Comment – Screenshots
GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26, CMS-10434 #26	AQM2017-ABA ,   AQM2017-AdminScreen ,   AQM2017-AMM ,   AQM2017-BCS ,   AQM2017-CBP ,   AQM2017-CCP ,   AQM2017-CCS ,   AQM2017-CDF ,   AQM2017-CHL ,   AQM2017-CPA ,   AQM2017-FUA ,   AQM2017-FUH ,   AQM2017-FVA ,   AQM2017-HA1C ,   AQM2017-HPC ,   AQM2017-HPCMI ,   AQM2017-HVL ,   AQM2017-IET ,   AQM2017-MPM ,   AQM2017-MSC ,   AQM2017-OHD ,   AQM2017-PCO1 ,   AQM2017-PC03 ,   AQM2017-PCR ,   AQM2017-PPC ,   AQM2017-PQI01 ,   AQM2017-PQI05 ,   AQM2017-PQI08 ,   AQM2017-PQI15 ,   AQM2017-SAA ,   AQM2017-SSD ,   AQM2018-ABA ,   AQM2018-AdminScreen ,   AQM2018-AMM ,   AQM2018-AMR ,   AQM2018-BCS ,   AQM2018-CBP ,   AQM2018-CCP ,   AQM2018-CCS ,   AQM2018-CCW ,   AQM2018-CHL ,   AQM2018-COB ,   AQM2018-CPA ,   AQM2018-FUA FUM ,   AQM2018-FUH ,   AQM2018-FVA ,   AQM2018-HA1C ,   AQM2018-HPC ,   AQM2018-HPCMI ,   AQM2018-HVL ,   AQM2018-IET ,   AQM2018-MPM AD ,   AQM2018-MSC ,   AQM2018-OHD ,   AQM2018-PC01 AD ,   AQM2018-PC03 AD ,   AQM2018-PCR AD ,   AQM2018-PPC AD ,   AQM2018-PQI01 ,   AQM2018-PQI05 ,   AQM2018-PQI08 ,   AQM2018-PQI15 ,   AQM2018-SSA AD ,   AQM2018-SSD AD ,   CQM2017-ADD ,   CQM2017-AdminScreen ,   CQM2017-AMB ,   CQM2017-APC ,   CQM2017-APP ,   CQM2017-AUD ,   CQM2017-AWC ,   CQM2017-BHRA ,   CQM2017-CAP ,   CQM2017-CHL ,   CQM2017-CIS ,   CQM2017-CLABSI ,   CQM2017-CPC ,   CQM2017-DEV ,   CQM2017-FPC ,   CQM2017-FUH ,   CQM2017-IMA ,   CQM2017-LBW ,   CQM2017-MMA ,   CQM2017-PC02 ,   CQM2017-PDENT ,   CQM2017-PPC ,   CQM2017-SEAL ,   CQM2017-SRA ,   CQM2017-StateSpecific ,   CQM2017-W15 ,   CQM2017-W34 ,   CQM2017-WCC ,   CQM2018-ADD-CH ,   CQM2018-AdminScreen ,   CQM2018-AMB-CH ,   CQM2018-AMR-CH ,   CQM2018-APC-CH ,   CQM2018-APP-CH ,   CQM2018-AUD-CH ,   CQM2018-AWC-CH ,   CQM2018-CAP-CH ,   CQM2018-CCP-CH ,   CQM2018-CCW-CH ,   CQM2018-CDF-CH ,   CQM2018-CHL-CH ,   CQM2018-CIS-CH ,   CQM2018-CLABSI-CH ,   CQM2018-CPC-CH ,   CQM2018-DEV-CH ,   CQM2018-FUH-CH ,   CQM2018-IMA-CH ,   CQM2018-LBW-CH ,   CQM2018-PC02-CH ,   CQM2018-PDENT-CH ,   CQM2018-PPC-CH ,   CQM2018-SEAL-CH ,   CQM2018-W15-CH ,   CQM2018-W34-CH ,   CQM2018-WCC-CH
GenIC #47 - Health Home Core Sets	HHQM1, HHQM11, HHQM13, HHQM19, HHQM4, HHQM15, HHQM3, HHQM7, HHQM10, HHQM12, HHQM16, HHQM18, HHQM20, HHQM2, HHQM5, HHQM6, HHQM17, HHQM8, HHQM9, HHQM14, HHQM21	Admin-Data-Source ,   Admin-Hybrid-Data-Source ,   Admin-Questions ,   Admin-Screen ,   Admin-Combined-Rates ,   HHQM-ABA ,   HHQM-AMB ,   HHQM-CBP ,   HHQM-CDF ,   HHQM-CTR ,   HHQM-FUH ,   HHQM-IET ,   HHQM-IU ,   HHQM-NFU ,   HHQM-PCR ,   HHQM-PQI92 ,   HHQM-SSGM ,   Hybrid-Data-Source ,   Hybrid-or-EHR ,   If-Data-Not-Reported ,   Technical-Assistance

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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	280	280	0	0	0	0
Annual Time Burden (Hours)	96,844	2,772	0	0	94,072	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: The previous approval inadvertently did not account for the full bank of burden hours requested in the supporting statement.

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Annual Cost to Federal Government: $17,800,000

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: 08/03/2017

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