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

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.