GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
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
CIB07242015-Fast-Track (1).pdf Instruction
CMS-10398 #51 Application Certification Statement - Section 1115(a) Ex 51 - 1115a extension state certification.docx Form and Instruction
CMS-10398 #51 1115(e) Extension State Certification 51 - 1115e extension state certification.docx Form and Instruction
CMS-10398 #51 1115(f) Extension State Certification 51 - 1115f extension state certification.docx Form and Instruction
CMS-10398 #51 Extension With Changes Template #51 - Extension with Changes Template_09-13-2016.doc Form and Instruction
51 - Supporting Statement Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions_11 13 17 rev.docx #51 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #51	Application Certification Statement - Section 1115(a) Extension	51 - 1115a extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	1115(e) Extension State Certification	51 - 1115e extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	1115(f) Extension State Certification	51 - 1115f extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	Extension With Changes Template	#51 - Extension with Changes Template_09-13-2016.doc	Yes	Yes	Fillable Fileable
Instruction			CIB07242015-Fast-Track (1).pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#51 - Supporting Statement	51 - Supporting Statement Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions_11 13 17 rev.docx	01/12/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.