OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202401-0938-016 · OMB 0938-1148 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-10398 #45 [Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application Form and Instruction New Available
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form Unchanged Available
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form Unchanged Repair queued
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 Available
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 Repair queued
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction Unchanged Repair queued
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template Form and Instruction Unchanged Repair queued
Form CMS-10398 #7 GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form Unchanged Available
Form CMS-10398 #7 GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment Form Unchanged Repair queued
Form CMS-10398 (GenIC#7 CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction Unchanged Available
Form CMS-10398 (GenIC#7 CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) Form and Instruction Unchanged Repair queued
Form CMS-10398. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form Unchanged Available
Form CMS-10398. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations Form Unchanged Repair queued
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 Available
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 Missing upstream
Form CMS-10398 #74 GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form Unchanged Available
Form CMS-10398 #74 GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form Unchanged Repair queued
Form CMS-10398 #37 GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction Unchanged Available
Form CMS-10398 #37 GenIC #37 (revision): Managed Care Rate Setting Guidance Form and Instruction Unchanged Repair queued
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form Unchanged Available
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form Unchanged Repair queued
Form cms-10398 #75 #75 (New): ARP 1135 State Plan Amendment Form Unchanged Repair queued
Form cms-10398 #75 #75 (New): ARP 1135 State Plan Amendment Form Unchanged Repair queued
Form CMS-10398 #74 #74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form Unchanged Repair queued
Form CMS-10398 #74 #74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials Form Unchanged Repair queued
Form CMS-10398 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction Unchanged Available
Form CMS-10398 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs Form and Instruction Unchanged Missing upstream
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction Unchanged Available
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits Form and Instruction Unchanged Repair queued
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form Unchanged Available
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 Form Unchanged Repair queued
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form Unchanged Repair queued
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports Form Unchanged Repair queued
Form CMS-10398 #72 GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form Unchanged Available
Form CMS-10398 #72 GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form Unchanged Repair queued
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction Unchanged Available
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group Form and Instruction Unchanged Repair queued
0938-1148.Justification of Non-sub Change (Burden Ceiling Increase)-1-30-24.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-01-30 Repair queued
0938-1148.Justification of Non-sub Change (Burden Ceiling Increase)-1-30-24.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-01-30 Repair queued
CMS-10398 - Supporting Statement A (2021 version 4).docx Supporting Statement A Uploaded 2021-04-23 Available
CMS-10398 - Supporting Statement A (2021 version 4).docx Supporting Statement A Uploaded 2021-04-23 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
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
ICR Details
StatusActive
Agency/SubagencyHHS/CMS
OMB Control No0938-1148
Type of Information CollectionNo material or nonsubstantive change to a currently approved collection
Previous ICR Reference No202103-0938-018
Agency Tracking NoCMCS
Date Submitted to OIRA2024-01-30
Requested Expiration Date1969-12-31