Information Collection

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.

⚠️ Notice: This information collection may be referencing outdated material.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 #59 GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form
Video 1 - Overview of the Standardized Monitoring Report Process.docx cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Instruction
Video 2 - Populating and Submitting Monitoring Templates.docx cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Instruction
Video 3 - Downloading 1115 Monitoring Report Templates.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
6 - 1115_SMI_Metrics_Tech_specs_v1 (version 2).pdf	Instruction
8 - 1115-SMI-Monitoring-Protocol-Template-Instructions (version 2).pdf	Instruction
9 - 1115-SMI-Monitoring-Report-Template-Instructions (version 2).pdf	Instruction
12 - SMI_SED_HIT_Plan_Instructions (version 2).pdf	Instruction
13 - smd18011.pdf	Instruction
CMS-10398 #59 Implementation Plan Template 4 - smi-impl-plan-template (version 2).pdf	Form
CMS-10398 $59 Monitoring Report Template 5 - 1115-SMI-Monitoring-Report-Template (version 2).pdf	Form
CMS-10398 #59 Monitoring Protocol Template 7 - 1115-SMI-Monitoring-Protocol-Template (version 2).pdf	Form
CMS-10398 #59 Monitoring Workbook 10 - 1115-SMI-Monitoring-Workbook_013020 (version 2).xlsm	Form and Instruction
CMS-10398 #59 Current Availability Assessment 11 - 1115-smi-current-availability-assessment_013020 (version 2).xlsm	Form and Instruction
GenIC #59 - Generic Supporting Statement (version 3).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Federal Enterprise Architecture Business Reference Module

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	110	110
Annual IC Time Burden (Hours)	3,140	3,140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.