Information Collection

GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions

IC 240816 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Instructions (final 3-21-20@755p).docx	Instruction
CMS-10398.GenIC#61 CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Templa CMS-10398#61 - Medicaid Disaster Relief SPA Template Final.docx	Form
CMS-10398.GenIC#61 - Medicaid Disaster SPA Template and Instructions Supporting Statement (final 3-21-20@755p).docx CMS-10398.GenIC#61 - Medicaid Disaster SPA Template and Instructions Supporting Statement	IC Document

IC Title:

GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Instructions (final 3-21-20@755p).docx		Yes	No	Printable Only
Form	CMS-10398.GenIC#61	CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Template	CMS-10398#61 - Medicaid Disaster Relief SPA Template Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10398.GenIC#61 - Medicaid Disaster SPA Template and Instructions Supporting Statement	CMS-10398.GenIC#61 - Medicaid Disaster SPA Template and Instructions Supporting Statement (final 3-21-20@755p).docx	03/21/2020

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