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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.