Template I1 – Initial Application Template – State Information
INTRODUCTION
In Template I1, States provide information about the amendment they are submitting. This template applies to Medicaid State plan amendments and amendments to a State’s CHIP program. This template must be completed for each separate package the State is submitting.
States should complete this template in accordance with the instructions in the Technical Guidance section below.
TECHNICAL GUIDANCE
Template I1 first asks for:
The name of the State or Territory.
The name of the Medicaid or CHIP agency.
The name of the State or Territory is automatically populated from the User Profile, which must be completed before Template I1 can be submitted for review and approval. Validation: If the State has not completed the User Profile, Template I1 can be saved but it cannot be submitted until the User Profile has been completed.
The name of the Medicaid or CHIP agency is automatically populated from Template P1 – State Profile, which must be completed before Template I1 can be submitted for review and approval. Validation: If the State has not completed Template P1, Template I1 can be saved but cannot be submitted until Template P1 has been completed.
Template I1 next asks the State to identify the type of package it is submitting. The following four choices are displayed. The State should select whichever of the four choices applies. The State can select only one of the four choices shown.
Intent to Modify Package (Concept Paper).
This is a paper describing in general terms what the State is considering in the way of modifying its currently approved State plan. Often known as a Concept Paper, this submission is intended to be a basis for discussion between the State and CMS. Since this is an informal submission, the 90-day clock for review and action by CMS does not apply.
If this choice is selected, the State should also complete Template Z1 – Intent to Modify.
Draft Submission Package.
This is normally a completed plan amendment package, but instead of submitting it formally for review and approval, the State is submitting the package to CMS for informal review and technical assistance. This is often done to help speed the approval process by ensuring that all potential technical and other issues have been addressed before the package is formally submitted to CMS for approval. Since this is an informal submission, the 90-day clock for review and action by CMS does not apply.
Official Submission Package.
This is a formal submission to CMS for review and approval of the Medicaid or CHIP plan amendment. Because this is a formal submission, the 90-day clock for review and action by CMS applies.
If either “Draft Submission Package” or “Official Submission Package” was selected under “SUBMISSION TYPE” above, the State will be asked for information about the authority under which the State’s package is being submitted. The following two choices will be displayed. The State should select whichever of the two choices applies. Only one choice can be selected.
Medicaid State Plan Amendment.
CHIP State Plan Amendment.
When the “SUBMISSION TYPE” and “SUBMISSION AUTHORITY” sections have been completed, the information provided by the State in those sections will be displayed. The State will then be asked to provide the following information about the Authorized Submitter and Key Contacts for the package.
Authorized Submitter Information
Name.
Title.
Telephone Number.
Email Address.
The above information is automatically populated from Template P1 – State Profile, which must be completed before Template I1 can be submitted for review and approval. Validation: If the State has not completed Template P1, Template I1 can be saved but cannot be submitted until Template P1 has been completed.
Key Contacts Information
Name.
Title.
Telephone Number.
Email Address.
The above information is automatically populated from Template P1 – State Profile, which must be completed before Template I1 can be submitted for review and approval. Validation: If the State has not completed Template P1, Template I1 can be saved but cannot be submitted until Template P1 has been completed.
If the State has more than one Key Contact for this package, the user can call up additional spaces in which the required information can be entered. For the each Key Contact entered, the following three choices will be displayed.
This is the primary contact for this submission package.
This is the secondary contact for this submission package.
This is the tertiary contact for this submission package.
For each Key Contact, the appropriate choice should be selected. Once a choice is selected, only the remaining choices will be displayed for selection for other Key Contacts.
If either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was selected in the “SUBMISSION AUTHORITY” section, and the “SUBMISSION TYPE” selected is either “Draft Submission Package” or “Official Submission Package”, the following will be displayed:
“State Plan Transition to MACPro”
“This submission reflects transitioning the current State Plan to the new State Plan without changes.”
The State should enter either “Y” (Yes) or “N” (No) in the space provided.
If the State enters “Y” (Yes), a field titled “Baseline Effective Date” will be displayed on each screen of the State Plan Amendment material included in this submission package. In each place where “Baseline Effective Date” is displayed, the State must enter the most recent approval date for this material as shown in the paper version of the State’s plan.
If the State enters “N” (No), a request for the following additional information will be displayed.
Proposed Effective Date. This should be entered as MM/DD/YYYY in the space provided.
Regardless of the selection made under “SUBMISSION AUTHORITY”, if the “SUBMISSION TYPE” selected is either “Draft Submission Package” or “Official Submission Package”, the following will be displayed:
EXECUTIVE SUMMARY
In the space provided, the State should provide a brief, summary description of the package being submitted, including the goals and objectives of the submission.
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer to understand the purpose of the package being submitted.
DISASTER-RELATED SUBMISSION
The following statement will be displayed:
“This submission is related to a disaster.”
The State should enter either “Y” (Yes) or “N” (No) in the space provided. If the “Y” (Yes) is entered, the State should provide a brief, summary description of the disaster or emergency for which the package is being submitted.
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer to understand the purpose of the package being submitted.
If either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was selected in the “SUBMISSION AUTHORITY” section, and the “SUBMISSION TYPE” selected is either “Draft Submission Package” or “Official Submission Package”, the following information will be requested:
FEDERAL BUDGET IMPACT
Federal Fiscal Year. This should be entered as YYYY in the space provided.
Amount. This should be entered as a dollar amount in the space provided.
The information requested is for the first year of the package. The same information is requested for the second year of the package, and should be entered in the same manner as the first year.
FEDERAL STATUTE/REGULATION CITATION
In the space provided, the State should enter the federal statute and/or regulatory citations under which the package is being submitted.
If “Official Submission Package” was selected under “SUBMISSION TYPE”, and if either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was selected in the “SUBMISSION AUTHORITY”, the following will be displayed.
GOVERNOR’S OFFICE REVIEW
Under this heading four choices will be displayed. The State should select whichever of the four choices applies. Only one of the four choices can be selected.
No comment.
Comments received.
If this choice is selected, the State should enter a summary of the comments received in the space provided.
Review Criteria
The summary must be sufficiently clear, detailed and complete to permit the reviewer to understand the comments made by the governor’s office.
No response within 45 days.
Other.
If “Other” is selected, the State should enter a description of “Other” in the space provided.
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer to understand the selection made.
For all Submission Types and Authorities, the following will be displayed.
AUTHORIZED SUBMITTER’S SIGNATURE
“ I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency.”
The Authorized Submitter’s electronic signature must be entered in the space provided. Validations: If the Authorized Submitter’s electronic signature is not entered in the space provided, this package can be saved but cannot be submitted until the signature is entered in the space provided.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Roy Trudel |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |