Information Collection

GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates

IC 237468 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material.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 #58 GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates Form and Instruction
58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Report Instructions.docx Instruction
58 - Monitoring Metrics for Demonstrations with Community Engagement and Other Eligibility and Coverage Policies.pdf Instruction
58 - Section 1115 Eligibility and Coverage Demonstrations Monitoring Metrics Technical Specifications.pdf Instruction
smd18002.pdf Other-SMDL
CMS-10398 #58 Implementation Plan Template 58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan Template.pdf Form and Instruction
CMS-10398 #58 Monitoring Protocol - Planned Metrics 58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Protocol.xlsx Form and Instruction
CMS-10398 #58 Monitoring Report 58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Report.docx Form and Instruction
GenIC 58 - Supporting Statement (2019 version 3).docx Generic Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates	Agency IC Tracking Number:	CMCS

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 #58	Implementation Plan Template	58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #58	Monitoring Protocol - Planned Metrics	58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Protocol.xlsx	Yes	Yes	Fillable Fileable
Instruction			58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Report Instructions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #58	Monitoring Report	58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Report.docx	Yes	Yes	Fillable Fileable
Instruction			58 - Monitoring Metrics for Demonstrations with Community Engagement and Other Eligibility and Coverage Policies.pdf	No		Printable Only
Instruction			58 - Section 1115 Eligibility and Coverage Demonstrations Monitoring Metrics Technical Specifications.pdf	Yes	Yes	Printable Only
Other-SMDL			smd18002.pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	3,080	3,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Supporting Statement	GenIC 58 - Supporting Statement (2019 version 3).docx	09/26/2019

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