Information Collection

GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)

IC 244016 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⚠️ Notice: This information collection may be referencing outdated material.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 #68 GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)	Form
CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Att 09-29-2020-1006(b)-SPA Template-Supp to Att.3.1-A (2020 version 3).docx	Form
CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Att 09-29-2020-1006(b)-SPA Template-Supp to Att. 3.1-B (2020 version 3).docx	Form
GenIC 68 - Generic Supporting Statement (2020 version 6).docx Generic Supporting Statement	IC Document

IC Title:

GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #68	SPA Coverage Template for Limitations (Supplement to Attachment 3.1-A)	09-29-2020-1006(b)-SPA Template-Supp to Att.3.1-A (2020 version 3).docx		Yes	Yes	Fillable Fileable
Form	CMS-10398 #68	SPA Coverage Template for Limitations (Supplement to Attachment 3.1-B)	09-29-2020-1006(b)-SPA Template-Supp to Att. 3.1-B (2020 version 3).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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	66	66
Annual IC Time Burden (Hours)	4,485	4,485
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	GenIC 68 - Generic Supporting Statement (2020 version 6).docx	10/27/2020

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