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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10398 #24 IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration	Form and Instruction	New	Repair queued
Form CMS-10398 #24 XV. Clinic Standard Template	Form	New	Repair queued
Form CMS-10398 #24 XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template	Form	New	Repair queued
Form CMS-10398 #24 XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template	Form	New	Repair queued
Form CMS-10398 #24 XII. Institutes for Mental Diseases (IMD) Standard Template	Form	New	Repair queued
Form CMS-10398 #24 XI. Medicaid Qualified Practitioner Services (Physician) Standard Template	Form	New	Repair queued
Form CMS-10398 #24 IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction	Form and Instruction	New	Repair queued
Form CMS-10398 #24 VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance	Form and Instruction	New	Repair queued
Form CMS-10398 #24 V. Clinic Upper Payment Limit (UPL) Guidance	Form and Instruction	New	Repair queued
Form CMS-10398 #24 II. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance	Form and Instruction	New	Repair queued
Form CMS-10398 #13 Attachment I – Inpatient Hospital Standard Template	Form	New	Repair queued
Form CMS-10398 #13 Attachment H – Outpatient Hospital Standard Template	Form	New	Repair queued
Form CMS-10398 #13 Attachment G – Nursing Facility Standard Template	Form	New	Repair queued
Form CMS-10398 #13 Attachment F – Inpatient Hospital UPL Guidance	Form and Instruction	New	Repair queued
Form CMS-10398 #13 Attachment D – Outpatient Hospital UPL Guidance	Form and Instruction	New	Repair queued
Form CMS-10398 #13 Attachment B – Nursing Facility UPL Guidance	Form and Instruction	New	Repair queued
Form # 1 CARTS	Form	New	Repair queued
Form CMS-10398 #59 Initial Availability Assessment	Form and Instruction	New	Repair queued
Form CMS-10398 #59 Monitoring Protocol Workbook	Form and Instruction	New	Repair queued
Form CMS-10398 #59 Monitoring Protocol Template	Form	New	Repair queued
Form CMS-10398 #59 Monitoring Report Workbook	Form and Instruction	New	Repair queued
Form CMS-10398 #59 Monitoring Report Template	Form	New	Repair queued
Form CMS-10398 #59 Implementation Plan Template	Form and Instruction	New	Repair queued
Form CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Attachment 3.1-B)	Form	New	Available
Form CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Attachment 3.1-A)	Form	New	Available
Form CMS-10398 #52 Section 438.6(c) Preprint	Form and Instruction	New	Available
Form CMS-10398 #1 CHIP Annual Report Template System (CARTS)	Form and Instruction	New	Available
Form CMS-10398 #64 Implementation Interview Protocol with Instructions for Interviewer	Form and Instruction	New	Repair queued
Form CMS-10398 #64 Demonstration Characteristics Interview Email Invitation and Grid	Form and Instruction	New	Available
Form CMS-10398 #64 Demonstration Characteristics Interview Questions	Form and Instruction	New	Available
Form CMS-10120 1932(a) State Plan Amendment Template	Form	New	Available
Form CMS-10398 #52 Section 438.6(c) pre-print	Form	New	Available
Form CMS-10398 #60 State Technical Assistance Needs Assessment Survey	Form and Instruction	New	Available
Form CMS-10398 #62 Quarterly Progress Report (QPR) Template	Form	New	Available
Form CMS-10398.GenIC#11 CMS-10398.GenIC#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-30-20)	Form and Instruction	New	Available
Form CMS-10398.GenIC#11 CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-30-20)	Form and Instruction	New	Available
Form CMS-10398.GenIC#61 CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Template	Form	New	Available
Form CMS-10398 #59 Current Availability Assessment	Form and Instruction	New	Available
Form CMS-10398 #59 Monitoring Workbook	Form and Instruction	New	Available
Form CMS-10398 #59 Monitoring Protocol Template	Form	New	Available
Form CMS-10398 $59 Monitoring Report Template	Form	New	Available
Form CMS-10398 #59 Implementation Plan Template	Form	New	Available
Form CMS-10398 #34 Track Changes - Template	Form and Instruction	New	Repair queued
Form CMS-10398 #34 Crosswalk - Template	Form and Instruction	New	Available
Form CMS-10398 #34 Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program	Form and Instruction	New	Available
Form CMS-10398 #58 Monitoring Report	Form and Instruction	New	Available
Form CMS-10398 #58 Monitoring Protocol - Planned Metrics	Form and Instruction	New	Available
Form CMS-10398 #58 Implementation Plan Template	Form and Instruction	New	Available
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report (quantitative reporting)	Form	New	Available
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other (quantitative reporting)	Form	New	Available
Form CMS-10398 #7 MACRA Cycle Vb, Round III: Final Report Template	Form	New	Available
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Final Report Template (qualitative report)	Form	New	Available
Form CMS-10398 #7 HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qualitative report)	Form	New	Available
Form 1 1115 SUD Monitoring Report Template	Form	New	Available
Form CMS-10398 #57 1115 SUD Metrics Template	Form	New	Available
Form CMS-10398 #54 EVV Good Faith Effort Request Form (Personal Care Services)	Form and Instruction	New	Available
Form CMS-10398 #54 EVV Good Faith Effort Request Form (Home Health Care Services)	Form and Instruction	New	Available
Form CMS-10398 #34 Template for Child Health Plan Under Title XXI of The Social Security Act Children’s Health Insurance Program	Form and Instruction	New	Available
Form CMS-10398 #56 PMDA Budget Neutrality Workbook Template	Form	New	Available
Form CMS-10398 #55 State Fee Schedule Drop	Form	New	Available
Form CMS-10398 #53 Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	Form and Instruction	New	Available
Form CMS-10398 #52 Section 438.6(c) pre-print	Form	New	Available
Form CMS-10398 #51 Extension With Changes Template	Form and Instruction	New	Available
Form CMS-10398 #51 1115(f) Extension State Certification	Form and Instruction	New	Available
Form CMS-10398 #51 1115(e) Extension State Certification	Form and Instruction	New	Available
Form CMS-10398 #51 Application Certification Statement - Section 1115(a) Extension	Form and Instruction	New	Available
Form CMS-10398 #50 Community First Choice (CFC) State Plan pre-print	Form	New	Available
Form CMS-10398 #48 Attachment B: Quality Measurement Data Reporting Templates	Form	New	Available
Form CMS-10398 #46 1915(i) Template	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #10 (Postpartum Women)	Form	New	Repair queued
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #9 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #8 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #7 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #6 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #5 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #4 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #3 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #2 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #1 (Postpartum Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #6 (Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #5 (Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #4 (Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #3 (Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #2 (Women)	Form	New	Available
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #1 (Women)	Form	New	Available
Form CMS-10398 #35 Eligibility and Enrollment Performance Indicators Template	Form	New	Available
Form CMS-10398 #34 Title XXI State Plan Template	Form	New	Available
Form CMS-10398 #33 FOA Preprint	Form	New	Available
Form CMS-10398 #32 Provider-Preventable Conditions Pre Print	Form	New	Available
Form CMS-10398 #31 Sample Template For State Settings’ Analysis	Form	New	Available
Form CMS-10398 #29 Medicaid Premiums and Cost Sharing	Form	New	Available
Form 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)	Form and Instruction	New	Available
Form CMS-10398 #27 Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan	Form and Instruction	New	Available
Form CMS-10398 #26 Medicaid Adult Core Set Measures Template	Form and Instruction	New	Available
Form CMS-10398 #24 IX - Funding Questions	Form	New	Available
Form CMS-10398 #24 XIV - Clinic Template	Form	New	Available
Form CMS-10398 #24 XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template	Form	New	Available
Form CMS-10398 #24 XII. Intermediate Care Facilitiy Template	Form	New	Available
Form CMS-10398 #24 UPL Institute Mental Disease Template	Form	New	Available
Form CMS-10398 #24 UPL Institute Mental Disease Template 1	Form	New	Available
Form CMS-10398 #24 UPL Physician Template	Form	New	Available
Form CMS-10398 #24 VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction	Form and Instruction	New	Available
Form CMS-10398 #24 Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance	Form and Instruction	New	Available
Form CMS-10398 #24 IV - Clinic Upper Payment Limit (UPL) Guidance	Form and Instruction	New	Available
Form CMS-10398 #24 II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance	Form and Instruction	New	Available
Form CMS-10398 #22 Health Home State Plan Amendment	Form	New	Available
Form CMS-10398 #22 Health Homes Administrative Component	Form	New	Available
Form CMS-10398 #21 SPA Attachments: Threshold Methodology for Identification of Applicable FMAP Rates	Form and Instruction	New	Available
Form CMS-10398 #18 Mock-up of Interim Form for Alternative Benefit Plans	Form and Instruction	New	Available
Form CMS-10398 #17 CS7 - Eligibility - Targeted Low-Income Children	Form	New	Available
Form CMS-10398 #17 CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women	Form	New	Available
Form CMS-10398 #17 CS28 - General Eligibility - Presumptive Eligibility for Children	Form	New	Available
Form CMS-10398 #17 CS27 - Non-Financial Requirements - Other Eligibility Standards	Form	New	Available
Form CMS-10398 #17 CS24 - General Eligibility - Eligibility Processing	Form	New	Available
Form CMS-10398 #17 CS23 - Non-Financial Requirements - Other Eligibility Standards	Form	New	Available
Form CMS-10398 #17 CS21 - Non-Financial Eligibility - Non-Payment of Premiums	Form	New	Available
Form CMS-10398 #17 CS20 - Non-Financial Eligibility - Substitution of Coverage	Form	New	Available
Form CMS-10398 #17 CS19 - Non-Financial Eligibility - Social Security Number	Form	New	Available
Form CMS-10398 #17 CS17 - Non-Financial Eligibility – Residency	Form	New	Available
Form CMS-10398 #17 CS16 - Other Eligibility Criteria - Spenddowns	Form	New	Available
Form CMS-10398 #15 CS15 - MAGI-Based Income Methodologies	Form	New	Available
Form CMS-10398 #17 CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	New	Available
Form CMS-10398 #17 CS13 - Eligibility - Deemed Newborns	Form	New	Available
Form CMS-10398 #17 CS12 - Eligibility - Dental Only Supplemental Coverage	Form	New	Available
Form CMS-10398 #17 CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	New	Available
Form CMS-10398 #17 CS10 - Eligibility - Children Who Have Access to Public Employee Coverage	Form	New	Available
Form CMS-10398 #17 CS9 - Eligibility - Coverage From Conception to Birth	Form	New	Available
Form CMS-10398 #17 CS8 - Eligibility - Targeted Low-Income Pregnant Women	Form	New	Available
Form CMS-10398 #17 CS3 - Eligibility for Medicaid Expansion Program	Form	New	Available
Form CMS-10398 #16 Federally Facilitated Marketplace and State Based Rules Integration Charts	Form	New	Available
Form CMS-10398 #16 Federally Facilitated Marketplace and State Based Rules Integration Charts	Form	New	Repair queued
Form CMS-10398 #15 Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL	Form and Instruction	New	Repair queued
Form CMS-10398 #15 Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals	Form and Instruction	New	Repair queued
Form CMS-10398 #15 Tab S14 – Medicaid Eligibility: AFDC Income Standards	Form and Instruction	New	Available
Form CMS-10398 #15 Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies	Form and Instruction	New	Available
Form CMS-10398 #15 Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority	Form and Instruction	New	Repair queued
Form CMS-10398 #13 Outpatient Hospital UPL Guidance	Form	New	Repair queued
Form CMS-10398 #13 Inpatient Hospital UPL Guidance	Form	New	Available
Form CMS-10398 #13 IP Template	Form	New	Available
Form CMS-10398 #13 OP Template	Form	New	Available
Form CMS-10398 #13 NF Template	Form	New	Available
Form CMS-10398 #13 Inpatient Hospital UPL Guidance	Form and Instruction	New	Available
Form CMS-10398 #13 Outpatient Hospital UPL Guidance	Form and Instruction	New	Available
Form CMS-10398 #13 Nursing Facility UPL Guidance	Form and Instruction	New	Available
Form CMS-10398 #11 Verification Plan Template	Form and Instruction	New	Available
Form CMS-10398 #10 Section 1115 Demonstration Program Application Guide	Form and Instruction	New	Repair queued
Form CMS-10398 #10 Long Term Services Benefit Specifications and Provider Qualifications	Form	New	Available
Form CMS-10398 #10 Long Term Services and Supports Form	Form	New	Available
Form CMS-10398 #10 BN Table Shell	Form	New	Available
Form CMS-10398 #10 Demonstration Financing Form	Form and Instruction	New	Available
Form CMS-10398 #10 Budget Neutrality Form	Form and Instruction	New	Available
Form CMS-10398 #10 Benefit Specifications and Provider Qualifications	Form	New	Repair queued
Form CMS-10398 #9 Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	Form and Instruction	New	Available
Form CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum	Form and Instruction	New	Available
Form CMS-10398 #7 Cycle Vb. Connecting Kids to Coverage Final Report Template	Form and Instruction	New	Available
Form CMS-10398 #7 Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template	Form and Instruction	New	Available
Form CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)	Form and Instruction	New	Repair queued
Form CMS-10398 #5 Payment Suspension Screen Shots	Form	New	Available
Form CMS-10398 #1 Framework for the Annual Report of the Children’s Health Insurance Plans Under Title XXI of the Social Security Act	Form and Instruction	New	Source copy available
CMS-10398 - Supporting Statement for Generic Umbrella 12-27-17 Final [rev 02-23-2018 by OSORA PRA].docx	Supporting Statement A	Uploaded 2018-02-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction	New	IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form	New	XV. Clinic Standard Template
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form	New	XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form	New	XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form	New	XII. Institutes for Mental Diseases (IMD) Standard Template
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form	New	XI. Medicaid Qualified Practitioner Services (Physician) Standard Template
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction	New	IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction	New	VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction	New	V. Clinic Upper Payment Limit (UPL) Guidance
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction	New	II. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
245368	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Instruction	New
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Attachment I – Inpatient Hospital Standard Template
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Attachment H – Outpatient Hospital Standard Template
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Attachment G – Nursing Facility Standard Template
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Attachment F – Inpatient Hospital UPL Guidance
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Attachment D – Outpatient Hospital UPL Guidance
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Attachment B – Nursing Facility UPL Guidance
245363	GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Instruction	New
245181	GenIC #1 (Revised): CHIP Annual Report Template System (CARTS)	Form	New	CARTS
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form and Instruction	New	Initial Availability Assessment
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form and Instruction	New	Monitoring Protocol Workbook
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form	New	Monitoring Protocol Template
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form and Instruction	New	Monitoring Report Workbook
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form	New	Monitoring Report Template
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Form and Instruction	New	Implementation Plan Template
244836	GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	Instruction	New
244016	GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)	Form	New	SPA Coverage Template for Limitations (Supplement to Attachment 3.1-B)
244016	GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)	Form	New	SPA Coverage Template for Limitations (Supplement to Attachment 3.1-A)
243372	GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	Form and Instruction	New	Section 438.6(c) Preprint
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	CHIP Annual Report Template System (CARTS)
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	Implementation Interview Protocol with Instructions for Interviewer
242071	GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations	Form and Instruction	New	Demonstration Characteristics Interview Email Invitation and Grid
242071	GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations	Other-Introductory Email: Demonstration Characteristics Intervie	New
242071	GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations	Form and Instruction	New	Demonstration Characteristics Interview Questions
241971	GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template	Form	New	1932(a) State Plan Amendment Template
241795	GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	Other-Pre-print Example: COVID19	New
241795	GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	Form	New	Section 438.6(c) pre-print
241474	GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders	Instruction	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	State Technical Assistance Needs Assessment Survey
241052	GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act	Form	New	Quarterly Progress Report (QPR) Template
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	CMS-10398.GenIC#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-30-20)
241032	CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum	Form and Instruction	New	CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-30-20)
240816	GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions	Form	New	CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Template
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 and Instruction	New	Current Availability Assessment
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	New	Monitoring Workbook
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	New	Monitoring Protocol Template
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	New	Monitoring Report Template
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Instruction	New
240771	GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	New	Implementation Plan Template
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	Track Changes - Template
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	Crosswalk - Template
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	Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
237468	GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates	Form and Instruction	New	Monitoring Report
237468	GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates	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	Monitoring Protocol - Planned Metrics
237468	GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates	Form and Instruction	New	Implementation Plan Template
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	HEALTHY KIDS Cycle Vb: Monthly Report (quantitative reporting)
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	HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other (quantitative reporting)
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	MACRA Cycle Vb, Round III: Final Report Template
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	HEALTHY KIDS Cycle Vb: Final Report Template (qualitative report)
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	HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qualitative report)
236005	GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	Form	New	1115 SUD Monitoring Report Template
236005	GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	Form	New	1115 SUD Metrics Template
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	EVV Good Faith Effort Request Form (Personal Care Services)
233660	GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests	Form and Instruction	New	EVV Good Faith Effort Request Form (Home Health Care Services)
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	Template for Child Health Plan Under Title XXI of The Social Security Act Children’s Health Insurance Program
231323	GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook	Instruction	New
231323	GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook	Form	New	PMDA Budget Neutrality Workbook Template
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	Instruction	New
231119	GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid	Form	New	State Fee Schedule Drop
230306	GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	Other-SMD Letter 17-003 (Strategies to Address the Opioid Epidem	New
230306	GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	Form and Instruction	New	Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols
229740	GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	Form	New	Section 438.6(c) pre-print
229739	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Instruction	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	Extension With Changes Template
229739	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction	New	1115(f) Extension State Certification
229739	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction	New	1115(e) Extension State Certification
229739	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction	New	Application Certification Statement - Section 1115(a) Extension
229737	GenIC #50 (Extension w/o change): Community First Choice State Plan	Form	New	Community First Choice (CFC) State Plan pre-print
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	Form	New	Attachment B: Quality Measurement Data Reporting Templates
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	1915(i) Template
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #10 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #9 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #8 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #7 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #6 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #5 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #4 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #3 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #2 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #1 (Postpartum Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #6 (Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #5 (Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #4 (Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #3 (Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #2 (Women)
229715	GenIC #45 (Extension w/o change): Maternal and Infant Health Quality	Form	New	Maternal and Infant Health (MIH) Quality Screenshot #1 (Women)
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	Eligibility and Enrollment Performance Indicators Template
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	Title XXI State Plan Template
229694	GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062)	Form	New	FOA Preprint
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)	Instruction	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	Provider-Preventable Conditions Pre Print
229692	GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans	Form	New	Sample Template For State Settings’ Analysis
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	Form	New	Medicaid Premiums and Cost Sharing
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	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State’s Medicaid Management Information System (MMIS)
229686	GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2	Form and Instruction	New	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
229683	GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template	Form and Instruction	New	Medicaid Adult Core Set Measures Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	IX - Funding Questions
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	XIV - Clinic Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	XII. Intermediate Care Facilitiy Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	UPL Institute Mental Disease Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	UPL Institute Mental Disease Template 1
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form	New	UPL Physician Template
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form and Instruction	New	VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form and Instruction	New	Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form and Instruction	New	IV - Clinic Upper Payment Limit (UPL) Guidance
229682	GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers	Form and Instruction	New	II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
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	Health Home State Plan Amendment
229681	GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA)	Form	New	Health Homes Administrative Component
229616	GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment	Instruction	New
229616	GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment	Form and Instruction	New	SPA Attachments: Threshold Methodology for Identification of Applicable FMAP Rates
229615	GenIC #18 (Extension w/o change): Alternative Benefit Plans	Form and Instruction	New	Mock-up of Interim Form for Alternative Benefit Plans
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS7 - Eligibility - Targeted Low-Income Children
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS28 - General Eligibility - Presumptive Eligibility for Children
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS27 - Non-Financial Requirements - Other Eligibility Standards
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS24 - General Eligibility - Eligibility Processing
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS23 - Non-Financial Requirements - Other Eligibility Standards
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS21 - Non-Financial Eligibility - Non-Payment of Premiums
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS20 - Non-Financial Eligibility - Substitution of Coverage
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS19 - Non-Financial Eligibility - Social Security Number
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS17 - Non-Financial Eligibility – Residency
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS16 - Other Eligibility Criteria - Spenddowns
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS15 - MAGI-Based Income Methodologies
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS13 - Eligibility - Deemed Newborns
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS12 - Eligibility - Dental Only Supplemental Coverage
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS10 - Eligibility - Children Who Have Access to Public Employee Coverage
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS9 - Eligibility - Coverage From Conception to Birth
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS8 - Eligibility - Targeted Low-Income Pregnant Women
229614	GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form	New	CS3 - Eligibility for Medicaid Expansion Program
229613	GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool	Form	New	Federally Facilitated Marketplace and State Based Rules Integration Charts
229613	GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool	Form	New	Federally Facilitated Marketplace and State Based Rules Integration Charts
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S14 – Medicaid Eligibility: AFDC Income Standards
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies
229612	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Form and Instruction	New	Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Outpatient Hospital UPL Guidance
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	Inpatient Hospital UPL Guidance
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	IP Template
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	OP Template
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	New	NF Template
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Inpatient Hospital UPL Guidance
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Outpatient Hospital UPL Guidance
229611	GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	New	Nursing Facility UPL Guidance
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	Verification Plan Template
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction	New	Section 1115 Demonstration Program Application Guide
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form	New	Long Term Services Benefit Specifications and Provider Qualifications
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form	New	Long Term Services and Supports Form
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form	New	BN Table Shell
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Instruction	New
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction	New	Demonstration Financing Form
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction	New	Budget Neutrality Form
229609	GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form	New	Benefit Specifications and Provider Qualifications
229608	GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	Form and Instruction	New	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
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	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
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	Cycle Vb. Connecting Kids to Coverage Final Report Template
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	Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template
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	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)
229606	GenIC #5 (Extension w/o change): Medicaid Payment Suspensions	Form	New	Payment Suspension Screen Shots
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	Framework for the Annual Report of the Children’s Health Insurance Plans Under Title XXI of the Social Security Act

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 201712-0938-019
Status: Historical 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
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/29/2017
Terms of Clearance:

table that charts list comparision

	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
   Statute at Large: 21 Stat. 2101
   Statute at Large: 21 Stat. 1115
   Statute at Large: 19 Stat. 1901
  

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

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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: 61

table that charts list of burden

IC Title	Form No.	Form Name
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 # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	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	II. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance ,   V. Clinic Upper Payment Limit (UPL) Guidance ,   VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance ,   IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction ,   XI. Medicaid Qualified Practitioner Services (Physician) Standard Template ,   XII. Institutes for Mental Diseases (IMD) Standard Template ,   XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template ,   XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template ,   XV. Clinic Standard Template ,   IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration
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 # 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 #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 #1 (Revised): CHIP Annual Report Template System (CARTS)	# 1	CARTS
GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS)	CMS-10398 #1	CHIP Annual Report Template System (CARTS)
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 ,   Demonstration Financing Form ,   BN Table Shell ,   Long Term Services and Supports Form ,   Long Term Services Benefit Specifications and Provider Qualifications ,   Section 1115 Demonstration Program Application Guide
GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan	CMS-10398 #11	Verification Plan Template
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	Nursing Facility UPL Guidance ,   Outpatient Hospital UPL Guidance ,   Inpatient Hospital UPL Guidance ,   NF Template ,   OP Template ,   IP Template ,   Inpatient Hospital UPL Guidance ,   Outpatient Hospital UPL Guidance
GenIC #13 (Revision): 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	Attachment B – Nursing Facility UPL Guidance ,   Attachment D – Outpatient Hospital UPL Guidance ,   Attachment F – Inpatient Hospital UPL Guidance ,   Attachment G – Nursing Facility Standard Template ,   Attachment H – Outpatient Hospital Standard Template ,   Attachment I – Inpatient Hospital Standard Template
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 S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility ,   Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process
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 #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 #18 (Extension w/o change): Alternative Benefit Plans	CMS-10398 #18	Mock-up of Interim Form for Alternative Benefit Plans
GenIC #2 (Extension w/o change): Medicaid Managed Care Data Collection
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 #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 #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	II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance ,   IV - Clinic Upper Payment Limit (UPL) Guidance ,   Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance ,   VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction ,   UPL Physician Template ,   UPL Institute Mental Disease Template 1 ,   UPL Institute Mental Disease Template ,   XII. Intermediate Care Facilitiy Template ,   XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template ,   XIV - Clinic Template ,   IX - Funding Questions
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 #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 #29 (Extension w/o change): Medicaid Cost Sharing	CMS-10398 #29	Medicaid Premiums and Cost Sharing
GenIC #30 (Extension w/o change): State Reporting Medicaid Payment Suspension
GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans	CMS-10398 #31	Sample Template For State Settings’ Analysis
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 #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 #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 #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 #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 #37 (Rev): Managed Care Rate Setting Guidance
GenIC #37 (Revised): Managed Care Rate Setting Guidance
GenIC #37 (Revision) Managed Care Rate Setting Guidance
GenIC #43 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services
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 #2 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #3 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #4 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #5 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #6 (Women) ,   Maternal and Infant Health (MIH) Quality Screenshot #1 (Postpartum 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)
GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services	CMS-10398 #46	1915(i) Template
GenIC #47 (Extension w/o change): Health Home Core Sets
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 #5 (Extension w/o change): Medicaid Payment Suspensions	CMS-10398 #5	Payment Suspension Screen Shots
GenIC #50 (Extension w/o change): Community First Choice State Plan	CMS-10398 #50	Community First Choice (CFC) State Plan pre-print
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 #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 #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	CMS-10398 #52	Section 438.6(c) pre-print
GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products	CMS-10398 #52	Section 438.6(c) Preprint
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 #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 #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid	CMS-10398 #55	State Fee Schedule Drop
GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook	CMS-10398 #56	PMDA Budget Neutrality Workbook Template
GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	1, CMS-10398 #57	1115 SUD Metrics Template ,   1115 SUD Monitoring Report Template
GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations	CMS-10398 #59, CMS-10398 #59, CMS-10398 #59, CMS-10398 #59, CMS-10398 #59, CMS-10398 #59	Implementation Plan Template ,   Monitoring Report Template ,   Monitoring Report Workbook ,   Monitoring Protocol Template ,   Monitoring Protocol Workbook ,   Initial 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 #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 #62 (New): Data Collection for Section 1003 of the SUPPORT Act	CMS-10398 #62	Quarterly Progress Report (QPR) Template
GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template	CMS-10120	1932(a) State Plan Amendment Template
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 Email Invitation and Grid ,   Demonstration Characteristics Interview Questions ,   Implementation Interview Protocol with Instructions for Interviewer
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)
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 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 (Formerly Known as the Semi-Annual Report) ,   Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
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 #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

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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	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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