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

ICR 202401-0938-016

OMB: 0938-1148

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10398 #45 [Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application Form and Instruction	New
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
Form CMS-10398 #34 [Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	Unchanged
Form CMS-10398 #34 [Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	Unchanged
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction	Unchanged
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction	Unchanged
Form CMS-10398 #7 GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form	Unchanged
Form CMS-10398 #7 GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form	Unchanged
Form CMS-10398 (GenIC#7 CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction	Unchanged
Form CMS-10398 (GenIC#7 CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction	Unchanged
Form CMS-10398. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	Unchanged
Form CMS-10398. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	Unchanged
Form CMS-10398 #76 GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group Form and Instruction	Unchanged
Form CMS-10398 #76 GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group Form and Instruction	Unchanged
Form CMS-10398 #74 GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
Form CMS-10398 #74 GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
Form CMS-10398 #37 GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction	Unchanged
Form CMS-10398 #37 GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction	Unchanged
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
Form cms-10398 #75 #75 (New): ARP 1135 State Plan Amendment Form	Unchanged
Form cms-10398 #75 #75 (New): ARP 1135 State Plan Amendment Form	Unchanged
Form CMS-10398 #74 #74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
Form CMS-10398 #74 #74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
Form CMS-10398 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction	Unchanged
Form CMS-10398 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction	Unchanged
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction	Unchanged
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction	Unchanged
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form	Unchanged
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form	Unchanged
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form	Unchanged
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form	Unchanged
Form CMS-10398 #72 GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form	Unchanged
Form CMS-10398 #72 GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form	Unchanged
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction	Unchanged
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction	Unchanged
0938-1148.Justification of Non-sub Change (Burden Ceiling Increase)-1-30-24.docx Justification for No Material/Nonsubstantive Change	2024-01-30
0938-1148.Justification of Non-sub Change (Burden Ceiling Increase)-1-30-24.docx Justification for No Material/Nonsubstantive Change	2024-01-30
CMS-10398 - Supporting Statement A (2021 version 4).docx Supporting Statement A	2021-04-23
CMS-10398 - Supporting Statement A (2021 version 4).docx Supporting Statement A	2021-04-23

IC Document Collections

IC ID	Document Title	Status
264851	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application Form and Instruction	New
263802	GenIC #37 (Revision): Managed Care Rate Setting Guidance Other-2023-2024 Managed Care Rate Guidance	Unchanged
263409	GenIC #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
263409	GenIC #17 (Revision): CHIP State Plan Eligibility Form	Unchanged
262311	[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	Unchanged
262311	[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction	Unchanged
260938	GenIC #64 (Revision): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations Other-Demonstration Characteristics Interview Introductory Email	Unchanged
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Other-#1 Video: Overview of the Standardized Monitoring Report P	Unchanged
259813	GenIC #37 (Revision): Managed Care Rate Setting Guidance Other-2022-2023 Managed Care Rate Guidance	Unchanged
258773	#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction	Unchanged
258773	#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction	Unchanged
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form	Unchanged
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form	Unchanged
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction	Unchanged
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction	Unchanged
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	Unchanged
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form	Unchanged
252863	GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group Form and Instruction	Unchanged
252863	GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group Form and Instruction	Unchanged
252860	GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
252860	GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
252244	GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support Other-Introductory Email (from CMS to State Medicaid Director)	Unchanged
252106	GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates Instruction	Unchanged
251810	GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction	Unchanged
251810	GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction	Unchanged
251152	#17 (Revision): CHIP State Plan Eligibility Form	Unchanged
251152	#17 (Revision): CHIP State Plan Eligibility Form	Unchanged
251150	#75 (New): ARP 1135 State Plan Amendment Form	Unchanged
251150	#75 (New): ARP 1135 State Plan Amendment Form	Unchanged
251149	#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
251149	#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form	Unchanged
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction	Unchanged
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction	Unchanged
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction	Unchanged
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction	Unchanged
250720	GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form	Unchanged
250720	GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form	Unchanged
250101	GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form	Unchanged
250101	GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form	Unchanged
249074	GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form	Unchanged
249074	GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form	Unchanged
248500	GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction	Unchanged
248500	GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction	Unchanged
247999	GenIC #69 (Nonsubstantive Change): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID–19 Emergency Other-SMDL	Unchanged
247394	GenIC #71 (New): Reporting Requirements for State Planning Grants for Qualifying Community-Based Mobile Crisis Intervention Services During the COVID–19 Emergency Instruction	Unchanged
247285	GenIc #37 (Revised): Medicaid Managed Care Rate Development Guide (CMS-10398) Instruction	Unchanged
247050	GenIC #69 (New): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID-19 Emergency Other-SMDL	Unchanged
246350	GenIC Inventory Other-Inventory of Currently Approved GenICs	Unchanged