Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Forms and Documents

Document Name	Status
Form CMS-10398 #68 GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT) Form	New
Form CMS-10398 #1 GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS) Form and Instruction	New
Form CMS-10398 #64 GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations Form and Instruction	New
Form CMS-10120 GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template Form	New
Form CMS-10398 #52 GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products Form	New
Form CMS-10398 #60 GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders Form and Instruction	New
Form CMS-10398.GenIC#11 CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum Form and Instruction	New
Form CMS-10398 #59 GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	New
Form CMS-10398 #34 GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	New
Form CMS-10398 #58 GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates Form and Instruction	New
Form CMS-10398 #7 GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates) Form	New
Form CMS-10398 #54 GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests Form and Instruction	New
Form CMS-10398 #34 GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	New
Form CMS-10398 #56 GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook Form	New
Form CMS-10398 #55 GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid Form	New
Form CMS-10398 #53 GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols Form and Instruction	New
Form CMS-10398 #52 GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products Form	New
Form CMS-10398 #51 GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions Form and Instruction	New
Form CMS-10398 #46 GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services Form	New
Form CMS-10398 #45 GenIC #45 (Extension w/o change): Maternal and Infant Health Quality Form	New
Form CMS-10398 #35 GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators Form	New
Form CMS-10398 #34 GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP Form	New
Form CMS-10398 #33 GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062) Form	New
Form CMS-10398 #32 GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) Form	New
Form CMS-10398 #28 GenIC #28 (Extension w/o change): MMIS APD Template NCCI Coding Initiative Form and Instruction	New
Form CMS-10398 #27 GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2 Form and Instruction	New
Form CMS-10398 #26 GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template Form and Instruction	New
Form CMS-10398 #22 GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA) Form	New
Form CMS-10398 #21 GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment Form and Instruction	New
Form CMS-10398 #18 GenIC #18 (Extension w/o change): Alternative Benefit Plans Form and Instruction	New
Form CMS-10398 #17 GenIC #17 (Extension w/o change): CHIP State Plan Eligibility Form	New
Form CMS-10398 #16 GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool Form	New
Form CMS-10398 #15 GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility Form and Instruction	New
Form CMS-10398 #11 GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan Form and Instruction	New
Form CMS-10398 #10 GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application Form	New
Form CMS-10398 #9 GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program Form and Instruction	New
Form CMS-10398 #7 GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final Form and Instruction	New
Form CMS-10398 #5 GenIC #5 (Extension w/o change): Medicaid Payment Suspensions Form	New
Form CMS-10398 #1 GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs) Form and Instruction	New
CMS-10398 - Supporting Statement for Generic Umbrella 12-27-17 Final [rev 02-23-2018 by OSORA PRA].docx Supporting Statement A	2018-02-27

IC Document Collections

IC ID	Document Title	Status
244016	GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT) Form	New
243372	GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products Other-Example	New
243222	GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS) Form and Instruction	New
242079	GenIC #37 (Revised): Managed Care Rate Setting Guidance Instruction	New
242071	GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations Form and Instruction	New
241971	GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template Form	New
241795	GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products Form	New
241474	GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders Form and Instruction	New
241052	GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act Instruction	New
241032	CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum Form and Instruction	New
240816	GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions Instruction	New
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	New
238387	GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	New
237468	GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates Form and Instruction	New
236649	GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates) Form	New
236005	GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates Instruction	New
234743	GenIC #37 (Revision) Managed Care Rate Setting Guidance Instruction	New
233660	GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests Form and Instruction	New
232065	GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	New
231323	GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook Form	New
231136	GenIC #37 (Rev): Managed Care Rate Setting Guidance Other-2017-2018 Medicaid Managed Care Rate Development Guide	New
231119	GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid Form	New
230306	GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols Form and Instruction	New
229740	GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products Form	New
229739	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions Form and Instruction	New
229737	GenIC #50 (Extension w/o change): Community First Choice State Plan Instruction	New
229736	GenIC #48 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services Instruction	New
229735	GenIC #47 (Extension w/o change): Health Home Core Sets Instruction	New
229734	GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services Form	New
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality Form	New
229713	GenIC #43 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services Instruction	New
229711	GenIC #37 (Extension w/o change): Managed Care Rate Setting Guidance Instruction	New
229709	GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators Form	New
229697	GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP Form	New
229694	GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062) Form	New
229693	GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) Form	New
229692	GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans Instruction	New
229691	GenIC #30 (Extension w/o change): State Reporting Medicaid Payment Suspension	New
229688	GenIC #29 (Extension w/o change): Medicaid Cost Sharing Instruction	New
229687	GenIC #28 (Extension w/o change): MMIS APD Template NCCI Coding Initiative Form and Instruction	New
229686	GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2 Form and Instruction	New
229683	GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template Form and Instruction	New
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers Instruction	New
229681	GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA) Form	New
229616	GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment Form and Instruction	New
229615	GenIC #18 (Extension w/o change): Alternative Benefit Plans Form and Instruction	New
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility Form	New
229613	GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool Form	New
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility Form and Instruction	New
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Instruction	New
229610	GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan Form and Instruction	New
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application Form	New
229608	GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program Form and Instruction	New
229607	GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final Form and Instruction	New
229606	GenIC #5 (Extension w/o change): Medicaid Payment Suspensions Form	New
229605	GenIC #2 (Extension w/o change): Medicaid Managed Care Data Collection Instruction	New
229604	GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs) Form and Instruction	New

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 201712-0938-019
Status: Active	Previous ICR Reference No: 201410-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/01/2018
	Date Received in OIRA: 12/29/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved	02/28/2018
Responses	6,720	0	6,720
Time Burden (Hours)	154,104	0	154,104
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 19 Stat. 1915 Name of Statute: null
   Statute at Large: 21 Stat. 2101 Name of Statute: null
   Statute at Large: 21 Stat. 1115 Name of Statute: null
   Statute at Large: 19 Stat. 1901 Name of Statute: null
  

Citations for New Statutory Requirements: Statute at Large: 19 Stat. 1915 Name of Statute: null
Statute at Large: 21 Stat. 2101 Name of Statute: null
Statute at Large: 21 Stat. 1115 Name of Statute: null
Statute at Large: 19 Stat. 1901 Name of Statute: null

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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:
	82 FR 11224	02/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 58613	12/13/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 57

IC Title	Form No.	Form Name
GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook	CMS-10398 #56	PMDA Budget Neutrality Workbook Template
GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	CMS-10398 #34, CMS-10398 #34, CMS-10398 #34	Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program ,   Crosswalk - Template ,   Track Changes - Template
GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators	CMS-10398 #35	Eligibility and Enrollment Performance Indicators Template
GenIC #37 (Extension w/o change): Managed Care Rate Setting Guidance
GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions	CMS-10398.GenIC#61	CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Template
GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	CMS-10398 #59, CMS-10398 $59, CMS-10398 #59, CMS-10398 #59, CMS-10398 #59	Implementation Plan Template ,   Monitoring Report Template ,   Monitoring Protocol Template ,   Monitoring Workbook ,   Current Availability Assessment
GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders	CMS-10398 #60	State Technical Assistance Needs Assessment Survey
GenIC #48 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services	CMS-10398 #48	Attachment B: Quality Measurement Data Reporting Templates
GenIC #50 (Extension w/o change): Community First Choice State Plan	CMS-10398 #50	Community First Choice (CFC) State Plan pre-print
GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs)	CMS-10398 #1	Framework for the Annual Report of the Children’s Health Insurance Plans Under Title XXI of the Social Security Act
GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #15, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17	CS3 - Eligibility for Medicaid Expansion Program ,   CS8 - Eligibility - Targeted Low-Income Pregnant Women ,   CS9 - Eligibility - Coverage From Conception to Birth ,   CS10 - Eligibility - Children Who Have Access to Public Employee Coverage ,   CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage ,   CS12 - Eligibility - Dental Only Supplemental Coverage ,   CS13 - Eligibility - Deemed Newborns ,   CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards ,   CS15 - MAGI-Based Income Methodologies ,   CS16 - Other Eligibility Criteria - Spenddowns ,   CS17 - Non-Financial Eligibility – Residency ,   CS19 - Non-Financial Eligibility - Social Security Number ,   CS20 - Non-Financial Eligibility - Substitution of Coverage ,   CS21 - Non-Financial Eligibility - Non-Payment of Premiums ,   CS23 - Non-Financial Requirements - Other Eligibility Standards ,   CS24 - General Eligibility - Eligibility Processing ,   CS27 - Non-Financial Requirements - Other Eligibility Standards ,   CS28 - General Eligibility - Presumptive Eligibility for Children ,   CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women ,   CS7 - Eligibility - Targeted Low-Income Children
GenIC #37 (Rev): Managed Care Rate Setting Guidance
GenIC #37 (Revision) Managed Care Rate Setting Guidance
GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	1, CMS-10398 #57	1115 SUD Monitoring Report Template ,   1115 SUD Metrics Template
GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	CMS-10398 #52	Section 438.6(c) Preprint
GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15, CMS-10398 #15	Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority ,   Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies ,   Tab S14 – Medicaid Eligibility: AFDC Income Standards ,   Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals ,   Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives ,   Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women ,   Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19 ,   Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group ,   Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children ,   Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL ,   Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives ,   Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21 ,   Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance ,   Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children ,   Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis ,   Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents ,   Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services ,   Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency ,   Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process ,   Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	CMS-10398 #9	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24	Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance ,   XII. Intermediate Care Facilitiy Template ,   II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance ,   XIV - Clinic Template ,   XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template ,   IX - Funding Questions ,   IV - Clinic Upper Payment Limit (UPL) Guidance ,   UPL Institute Mental Disease Template 1 ,   UPL Institute Mental Disease Template ,   VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction ,   UPL Physician Template
GenIC #29 (Extension w/o change): Medicaid Cost Sharing	CMS-10398 #29	Medicaid Premiums and Cost Sharing
GenIC #47 (Extension w/o change): Health Home Core Sets
GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template	CMS-10120	1932(a) State Plan Amendment Template
GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	CMS-10398 #34	Template for Child Health Plan Under Title XXI of The Social Security Act Children’s Health Insurance Program
GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA)	CMS-10398 #22, CMS-10398 #22	Health Homes Administrative Component ,   Health Home State Plan Amendment
GenIC #28 (Extension w/o change): MMIS APD Template NCCI Coding Initiative	CMS-10398 #28	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State’s Medicaid Management Information System (MMIS)
GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services	CMS-10398 #46	1915(i) Template
GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062)	CMS-10398 #33	FOA Preprint
GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP	CMS-10398 #34	Title XXI State Plan Template
GenIC #2 (Extension w/o change): Medicaid Managed Care Data Collection
GenIC #5 (Extension w/o change): Medicaid Payment Suspensions	CMS-10398 #5	Payment Suspension Screen Shots
GenIC #30 (Extension w/o change): State Reporting Medicaid Payment Suspension
GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)	CMS-10398 #32	Provider-Preventable Conditions Pre Print
GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid	CMS-10398 #55	State Fee Schedule Drop
GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates)	CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7	HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qualitative report) ,   HEALTHY KIDS Cycle Vb: Final Report Template (qualitative report) ,   MACRA Cycle Vb, Round III: Final Report Template ,   HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other (quantitative reporting) ,   HEALTHY KIDS Cycle Vb: Monthly Report (quantitative reporting)
GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	CMS-10398 #52	Section 438.6(c) pre-print
GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act	CMS-10398 #62	Quarterly Progress Report (QPR) Template
GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests	CMS-10398 #54, CMS-10398 #54	EVV Good Faith Effort Request Form (Home Health Care Services) ,   EVV Good Faith Effort Request Form (Personal Care Services)
GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	CMS-10398 #52	Section 438.6(c) pre-print
GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment	CMS-10398 #21	SPA Attachments: Threshold Methodology for Identification of Applicable FMAP Rates
GenIC #18 (Extension w/o change): Alternative Benefit Plans	CMS-10398 #18	Mock-up of Interim Form for Alternative Benefit Plans
GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13	Outpatient Hospital UPL Guidance ,   Inpatient Hospital UPL Guidance ,   NF Template ,   OP Template ,   IP Template ,   Inpatient Hospital UPL Guidance ,   Outpatient Hospital UPL Guidance ,   Nursing Facility UPL Guidance
GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool	CMS-10398 #16, CMS-10398 #16	Federally Facilitated Marketplace and State Based Rules Integration Charts ,   Federally Facilitated Marketplace and State Based Rules Integration Charts
GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45, CMS-10398 #45	Maternal and Infant Health (MIH) Quality Screenshot #1 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #3 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #1 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #6 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #2 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #3 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #4 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #5 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #6 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #7 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #8 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #9 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #10 (Postpartum Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #2 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #4 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #5 (Women)
GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans	CMS-10398 #31	Sample Template For State Settings’ Analysis
CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum	CMS-10398.GenIC#11, CMS-10398.GenIC#11.	CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-30-20) ,   CMS-10398.GenIC#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-30-20)
GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates	CMS-10398 #58, CMS-10398 #58, CMS-10398 #58	Implementation Plan Template ,   Monitoring Protocol - Planned Metrics ,   Monitoring Report
GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS)	CMS-10398 #1	CHIP Annual Report Template System (CARTS)
GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	CMS-10398 #53	Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols
GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations	CMS-10398 #64, CMS-10398 #64, CMS-10398 #64	Demonstration Characteristics Interview Questions ,   Implementation Interview Protocol with Instructions for Interviewer ,   Demonstration Characteristics Interview Email Invitation and Grid
GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	CMS-10398 #10, CMS-10398 #10, CMS-10398 #10, CMS-10398 #10, CMS-10398 #10, CMS-10398 #10, CMS-10398 #10	Benefit Specifications and Provider Qualifications ,   Budget Neutrality Form ,   BN Table Shell ,   Demonstration Financing Form ,   Long Term Services and Supports Form ,   Long Term Services Benefit Specifications and Provider Qualifications ,   Section 1115 Demonstration Program Application Guide
GenIC #43 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services
GenIC #37 (Revised): Managed Care Rate Setting Guidance
GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	CMS-10398 #51, CMS-10398 #51, CMS-10398 #51, CMS-10398 #51	Application Certification Statement - Section 1115(a) Extension ,   1115(e) Extension State Certification ,   1115(f) Extension State Certification ,   Extension With Changes Template
GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan	CMS-10398 #11	Verification Plan Template
GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final	CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report) ,   Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template ,   Cycle Vb. Connecting Kids to Coverage Final Report Template ,   Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template	CMS-10398 #26	Medicaid Adult Core Set Measures Template
GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2	CMS-10398 #27	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)	CMS-10398 #68, CMS-10398 #68	SPA Coverage Template for Limitations (Supplement to Attachment 3.1-A) ,   SPA Coverage Template for Limitations (Supplement to Attachment 3.1-B)

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ICR Summary 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	6,720	6,720	0	0	0	0
Annual Time Burden (Hours)	154,104	154,104	0	0	0	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:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 12/29/2017

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