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GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

IC 240771 under ICR 201712-0938-019 · OMB 0938-1148.

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Instruction
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GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations CMCS
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 #59 Implementation Plan Template 4 - smi-impl-plan-template (version 2).pdf Yes Yes Fillable Fileable
Form CMS-10398 $59 Monitoring Report Template 5 - 1115-SMI-Monitoring-Report-Template (version 2).pdf Yes Yes Fillable Fileable
Instruction 6 - 1115_SMI_Metrics_Tech_specs_v1 (version 2).pdf Yes Yes Fillable Fileable
Form CMS-10398 #59 Monitoring Protocol Template 7 - 1115-SMI-Monitoring-Protocol-Template (version 2).pdf Yes Yes Fillable Fileable
Instruction 8 - 1115-SMI-Monitoring-Protocol-Template-Instructions (version 2).pdf Yes Yes Fillable Fileable
Instruction 9 - 1115-SMI-Monitoring-Report-Template-Instructions (version 2).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #59 Monitoring Workbook 10 - 1115-SMI-Monitoring-Workbook_013020 (version 2).xlsm Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #59 Current Availability Assessment 11 - 1115-smi-current-availability-assessment_013020 (version 2).xlsm Yes Yes Fillable Fileable
Instruction 12 - SMI_SED_HIT_Plan_Instructions (version 2).pdf Yes Yes Fillable Fileable
Instruction 13 - smd18011.pdf No   Printable Only
Instruction Video 1 - Overview of the Standardized Monitoring Report Process.docx https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ Yes Yes Fillable Fileable
Instruction Video 2 - Populating and Submitting Monitoring Templates.docx https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ Yes Yes Fillable Fileable
Instruction Video 3 - Downloading 1115 Monitoring Report Templates.docx https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ Yes Yes Fillable Fileable

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 110 0 110 0 0 0
Annual IC Time Burden (Hours) 3,140 0 3,140 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC #59 - Generic Supporting Statement (version 3).docx 04/21/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.