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

Medicaid and CHIP Program (MACPro) (CMS-10434)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Document Name Document Type
PRA Disclosure Statement 082919 (rev 08-30-2019).pdf Other-PRA Disclosure Statement
390-CQM 2018-CCW-C Contraceptive Care – All Women Ages 15-20 (CCW-CH) CQM2018 QSSI-CCW-CH.pdf Form and Instruction
385-CQM 2018-ADD-C CQM 2018 - Follow-Up Care for Children Prescribed Attent #26 CQM2018.pdf Form and Instruction
385-CQM 2018-ADD-C CQM 2018 - Follow-Up Care for Children Prescribed Attent #26 CQM2017.pdf Form and Instruction
429-AQM 2018 ABA-A AQM 2018 – Adult Body Mass Index Assessment (ABA) Core M AQM2017.pdf Form and Instruction
245-QSSI-MACPro-PR AQM, CQM & MIH - Additional Notes PRA document #26 Common Questions.pdf Form and Instruction
26 - Supporting Statement (2019 version 2).docx GenIC Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #26 (Extension) - Medicaid Adult and Child Core Set Measures	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PRA Disclosure Statement			PRA Disclosure Statement 082919 (rev 08-30-2019).pdf	No		Printable Only
Form and Instruction	385-CQM 2018-ADD-CH-PRA-D	CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document	#26 CQM2018.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	429-AQM 2018 ABA-AD PRA-D	AQM 2018 – Adult Body Mass Index Assessment (ABA) Core Measure PRA document	AQM2017.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	390-CQM 2018-CCW-CH-PRA-D	Contraceptive Care – All Women Ages 15-20 (CCW-CH)	CQM2018 QSSI-CCW-CH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	385-CQM 2018-ADD-CH-PRA-D	CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document	#26 CQM2017.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	245-QSSI-MACPro-PRA-AdditionalNotes-D	AQM, CQM & MIH - Additional Notes PRA document	#26 Common Questions.pdf	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	8,960	8,960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Supporting Statement	26 - Supporting Statement (2019 version 2).docx	08/30/2019

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