GenIC #26 (Extension) - Medicaid Adult and Child Core Set Measures

PRA Disclosure Statement Centers for Medicare & Medicaid Services (CMS) collects this
mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets
forth the authority for the submittal and collection of state plans and plan amendment information
in a format defined by CMS for the purpose of improving the state application and federal review
processes, improve federal program management of Medicaid programs and Children’s Health
Insurance Program, and to standardize Medicaid program data which covers basic requirements, and
individualized content that reflects the characteristics of the particular state's program. The
information will be used to monitor and analyze performance metrics related to the Medicaid and
Children’s Health Insurance Program in efforts to boost program integrity efforts, improve
performance and accountability across the programs. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law. According to the
Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1188. The time required to complete this information collection is
estimated to range from 1 hour to 80 hours per response (see below), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Time Per Response
GenIC #1 - Initial Application @ 8.5 hr/response
GenIC #2 - CHIP State Plan Eligibility @ 28 hr/response
GenIC #3 - Alternative Benefit Plans (ABPs) @ 13 hr/response
GenIC #15 - Medicaid State Plan Eligibility @ 20 hr/response
GenIC #22 - Health Home State Plan Amendment (SPA) @ 80 hr/response
GenIC #26 - Medicaid Adult and Child Core Set Measures @ 40 hr/response
GenIC # 45 - Maternal and Infant Health Quality @ 1 hr/response
GenIC #47 - Health Home Core Sets @ 40 hr/response