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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10398 #81 Vital Records Data Elements - Mortality and Natality	Form	New	Repair queued
Form CMS-10398 #43 CCBHC Cost Report	Form	New	Repair queued
Form CMS-10398 #45 Criteria Compliance Checklist	Form and Instruction	New	Available
Form CMS-10398 #45 Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs	Form and Instruction	New	Available
Form CMS-10398 #45 Application and Guidance to Participate in the Section 223 CCBHC Demonstration Program	Form and Instruction	New	Available
Form CMS-10398 #48 Quality Measurement Data Reporting Templates	Form and Instruction	New	Repair queued
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	Unchanged	Available
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form	Unchanged	Available
Form CS27 (Revised) General Eligibility – Continuous Eligibility	Form	Unchanged	Available
Form CS24 General Eligibility - Eligibility Processing	Form	Unchanged	Available
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form	Unchanged	Available
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form	Unchanged	Available
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form	Unchanged	Available
Form CS19 Non-Financial Eligibility - Social Security Number	Form	Unchanged	Available
Form CS18 Non-Financial Eligibility – Citizenship	Form	Unchanged	Available
Form CS17 Non-Financial Eligibility – Residency	Form	Unchanged	Available
Form CS16 Other Eligibility Criteria – Spenddowns	Form	Unchanged	Available
Form CS15 MAGI-Based Income Methodologies	Form	Unchanged	Available
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	Unchanged	Available
Form CS13 Eligibility - Deemed Newborns	Form	Unchanged	Available
Form CS12 Eligibility - Dental Only Supplemental Coverage	Form	Unchanged	Available
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	Unchanged	Available
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage	Form	Unchanged	Available
Form CS9 Eligibility - Coverage From Conception to Birth	Form	Unchanged	Available
Form CS8 Eligibility - Targeted Low-Income Pregnant Women	Form	Unchanged	Available
Form CS7 Eligibility - Targeted Low-Income Children	Form	Unchanged	Available
Form CS3 Eligibility for Medicaid Expansion Program	Form	Unchanged	Available
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Repair queued
Form CMS-10398 #34 Title XXI State Plan Template	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 Attachment 12h CMHC Interview Protocol with Instruction	Form and Instruction	Unchanged	Available
Form Attachment 12g IMD Interview Protocol with Instructions	Form and Instruction	Unchanged	Available
Form Attachment 11f Implementation Interview Protocol with Instructions	Form and Instruction	Unchanged	Available
Form Attachment 8b Annual Availability Assessment	Form and Instruction	Unchanged	Available
Form Attachment 8a Initial Availability Assessment	Form and Instruction	Unchanged	Available
Form Attachment 7b Monitoring Protocol Workbook	Form and Instruction	Unchanged	Available
Form Attachment 7a Monitoring Protocol Template	Form and Instruction	Unchanged	Available
Form Attachment 5b Monitoring Report Workbook	Form and Instruction	Unchanged	Available
Form Attachment 5a Monitoring Report Template	Form and Instruction	Unchanged	Available
Form Attachment 4 Implementation Plan Template	Form and Instruction	Unchanged	Available
Form CMS-10398 #79 COVID-19 Risk Corridor Reconciliation Reporting Template	Form and Instruction	Unchanged	Available
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	Form and Instruction	Unchanged	Repair queued
Form CMS-10398 #7 HK2022 and HK2023 Monthly Progress Report Template	Form	Unchanged	Available
Form CMS-10398 #7 HK2019 Monthly Progress Report with Targets Template	Form	Unchanged	Available
Form CMS-10398 #7 HK2019 and HK2020 Monthly Progress Report Template	Form	Unchanged	Available
Form CMS-10398 #7 Final Report Template	Form	Unchanged	Available
Form CMS-10398 #7 Semi-Annual Report Template	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 CMS-10398_GenIC_7-CycleVbMonthlyReportwTarget	Form and Instruction	Unchanged	Available
Form CMS-10398 (GenIC#7 CMS-10398_GenIC_7-CycleVbMonthlyReportwAIANTarget	Form and Instruction	Unchanged	Available
Form CMS-10398 (GenIC#7 CMS-10398_GenIC_7-CycleVbMonthlyReport508	Form and Instruction	Unchanged	Available
Form CMS-10398 (GenIC#7 CMS-10398_GenIC_7-CycleVbFinalSAR508	Form and Instruction	Unchanged	Available
Form CMS-10398 (GenIC#7 CMS-10398_GenIC_7-CycleVaSAR508	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#59 Initial Availability Assessment	Form and Instruction	Unchanged	Available
Form CMS-10398. GenIC # Monitoring Protocol Workbook	Form	Unchanged	Available
Form CMS-10398. GenIC#5 Monitoring Protocol Template	Form	Unchanged	Available
Form CMS-10398. GenIC # Monitoring Report Workbook	Form and Instruction	Unchanged	Available
Form CMS-10398. GenIC#5 Monitoring Report Template	Form	Unchanged	Available
Form CMS-10398. GenIC # Implementation Plan Template	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 Maternal and Infant Health Initiative Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Learning Collaborative Affinity Group Expression of Interest Form	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	Repair queued
HHS Qualifying Clinical Trial Attestation Form	Form	Unchanged	Available
Form CMS-10398 #74 Qualifying Clinical Trial Preprint (Attachment 3.1-B)	Form	Unchanged	Repair queued
Form CMS-10398 #74 Qualifying Clinical Trial Preprint (Attachment 3.1-A)	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 (#64) Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)	Form and Instruction	Unchanged	Available
Form CMS-10398 $64 Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)	Form and Instruction	Unchanged	Available
Form CMS-10398 #64 MCO Protocol with Instructions	Form and Instruction	Unchanged	Available
Form CMS-10398 #57 Monitoring Report Workbook	Form and Instruction	Unchanged	Available
Form CMS-10398 #57 Monitoring Report Template	Form	Unchanged	Available
Form CMS-10398 #57 Monitoring Protocol Workbook	Form and Instruction	Unchanged	Available
Form CMS-10398 #57 Monitoring Protocol Template	Form	Unchanged	Available
Form CMS-10398 #37 2022-2023 Medicaid Managed Care Rate Development Guide	Form and Instruction	Unchanged	Available
Form CMS-10398 #37 2021-2022 Medicaid Managed Care Rate Development Guide	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 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	Unchanged	Available
Form CMS-10398 #17 General Eligibility - Presumptive Eligibility for Children	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards (Revised)	Form	Unchanged	Available
Form CMS-10398 #17 General Eligibility - Eligibility Processing	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Eligibility - Non-Payment of Premiums	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Eligibility - Substitution of Coverage	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Eligibility - Social Security Number	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Eligibility – Citizenship (Reinstatement)	Form	Unchanged	Available
Form CMS-10398 #17 Non-Financial Eligibility – Residency	Form	Unchanged	Available
Form CMS-10398 #17 Other Eligibility Criteria – Spenddowns	Form	Unchanged	Available
Form CMS-10398 #17 MAGI-Based Income Methodologies	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Deemed Newborns	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Dental Only Supplemental Coverage	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Children Who Have Access to Public Employee Coverage	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Coverage From Conception to Birth	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Targeted Low-Income Pregnant Women	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility - Targeted Low-Income Children	Form	Unchanged	Available
Form CMS-10398 #17 Eligibility for Medicaid Expansion Program	Form	Unchanged	Available
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Repair queued
Form CMS-10398 #75 Template for Medicaid Section 1135 Waiver of SPA Submission Requirements	Form	Unchanged	Available
Form cms-10398 #75 Preprint Attachment 7.7C: COVID-19 Treatment	Form	Unchanged	Available
Form cms-10398 #75 Preprint Attachment 7.7B: COVID-19 Testing	Form	Unchanged	Available
Form cms-10398 #75 Preprint Attachment 7.7A: Vaccine and Vaccine Administration	Form	Unchanged	Available
Form cms-10398 #75 #75 (New): ARP 1135 State Plan Amendment	Form	Unchanged	Repair queued
Qualifying Clinical Trial Attestation Form	Form and Instruction	Unchanged	Available
Form CMS-10398 #74 Att. 3.1.-B (Qualifying Clinical Trial Draft Preprint)	Form	Unchanged	Available
Form CMS-10398 #74 Att. 3.1-A (Qualifying Clinical Trial Draft Preprint)	Form	Unchanged	Available
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 Guidance Questions_Master File_PRTF	Form	Unchanged	Available
Form CMS-10398 #24 Guidance Questions_Master File_Physician	Form	Unchanged	Available
Form CMS-10398 #24 Guidance Questions_Master File_IMD	Form	Unchanged	Available
Form CMS-10398 #24 Guidance Questions_Master File_ICF IID	Form	Unchanged	Available
Form CMS-10398 #24 Guidance Questions_Master File_Clinic	Form	Unchanged	Available
Form CMS-10398 #24 MACFIN_prtf-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #24 MACFIN_physician-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #24 MACFIN_mental-disease-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #24 MACFIN_intermediate-care-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #24 MACFIN_clinic-services-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #24 Standard Funding Questions	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	Repair queued
Form CMS-10398 #13 Guidance Questions: Outpatient	Form	Unchanged	Available
Form CMS-10398 #13 Guidance Questions: Nursing	Form	Unchanged	Available
Form CMS-10398 #13 Guidance Questions: Inpatient	Form	Unchanged	Available
Form CMS-10398 #13 MACFIN_nursing-facility-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #13 MACFIN_outpatient-upl-template	Form and Instruction	Unchanged	Available
Form CMS-10398 #13 MACFIN_inpatient-upl-template	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 Provider Info Mockup	Form	Unchanged	Available
Form CMS-64 Payment detail Form Mockup	Form	Unchanged	Available
Form CMS-64 SPVNarr Mockup	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 State Renewals Report	Form and Instruction	Unchanged	Available
Form CMS-10398 # 66 Unwinding Data Report Workbook	Form	Unchanged	Available
Form CMS-10398 #66 Screenshots: Unwinding Data Report	Form	Unchanged	Available
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 Expression of Interest Form	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 Expression of Interest Form	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	Available
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	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
266499	GenIC #81 (New): Improving Quality of Care and Outcomes Data for Pregnant Medicaid Beneficiaries and Newborn Infants through Linkage and Evaluation of VR, BC, DC, and TAF	Form	New	Vital Records Data Elements - Mortality and Natality
266499	GenIC #81 (New): Improving Quality of Care and Outcomes Data for Pregnant Medicaid Beneficiaries and Newborn Infants through Linkage and Evaluation of VR, BC, DC, and TAF	Instruction	New
265212	[Medicaid] GenIC #43 (Revised): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	Form	New	CCBHC Cost Report
265212	[Medicaid] GenIC #43 (Revised): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	Instruction	New
264851	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction	New	Criteria Compliance Checklist
264851	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction	New	Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs
264851	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction	New	Application and Guidance to Participate in the Section 223 CCBHC Demonstration Program
264850	[Medicaid] GenIC #48 (Revised): Behavioral Health Clinic Quality Data Reporting	Form and Instruction	New	Quality Measurement Data Reporting Templates
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	General Eligibility - Presumptive Eligibility for Pregnant Women
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility - Presumptive Eligibility for Children
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility – Continuous Eligibility
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility - Eligibility Processing
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Requirements - Other Eligibility Standards
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Non-Payment of Premiums
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Substitution of Coverage
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Social Security Number
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility – Citizenship
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility – Residency
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Other Eligibility Criteria – Spenddowns
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	MAGI-Based Income Methodologies
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Deemed Newborns
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Dental Only Supplemental Coverage
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Children Who Have Access to Public Employee Coverage
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Coverage From Conception to Birth
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Targeted Low-Income Pregnant Women
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Targeted Low-Income Children
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility for Medicaid Expansion Program
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Form	Unchanged
263409	GenIC #17 (Revision): CHIP State Plan Eligibility	Other-IG_CS3	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	Title XXI State Plan Template
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	Other-Track Change: Title XXI State Plan Template	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	Form and Instruction	Unchanged	CMHC Interview Protocol with Instruction
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	IMD Interview Protocol with Instructions
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Implementation Interview Protocol with Instructions
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Annual Availability Assessment
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Initial Availability Assessment
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Monitoring Protocol Workbook
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Monitoring Protocol Template
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Monitoring Report Workbook
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Monitoring Report Template
260271	GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Implementation Plan Template
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	COVID-19 Risk Corridor Reconciliation Reporting Template
258773	#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	Form and Instruction	Unchanged
258773	#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	Other-Frequently Asked Questions (FAQs)	Unchanged
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	Form	Unchanged	HK2022 and HK2023 Monthly Progress Report Template
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	Form	Unchanged	HK2019 Monthly Progress Report with Targets Template
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	Form	Unchanged	HK2019 and HK2020 Monthly Progress Report Template
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	Form	Unchanged	Final Report Template
256905	GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	Form	Unchanged	Semi-Annual Report Template
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	CMS-10398_GenIC_7-CycleVbMonthlyReportwTarget
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)	Form and Instruction	Unchanged	CMS-10398_GenIC_7-CycleVbMonthlyReportwAIANTarget
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)	Form and Instruction	Unchanged	CMS-10398_GenIC_7-CycleVbMonthlyReport508
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)	Form and Instruction	Unchanged	CMS-10398_GenIC_7-CycleVbFinalSAR508
254145	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)	Form and Instruction	Unchanged	CMS-10398_GenIC_7-CycleVaSAR508
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 and Instruction	Unchanged	Initial Availability Assessment
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	Unchanged	Monitoring Protocol Workbook
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	Unchanged	Monitoring Protocol Template
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction	Unchanged	Monitoring Report Workbook
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	Unchanged	Monitoring Report Template
253727	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form	Unchanged	Implementation Plan Template
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	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	Maternal and Infant Health Initiative Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Learning Collaborative Affinity Group Expression of Interest Form
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	Other-Fact Sheet	Unchanged
252860	GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	Form	Unchanged	HHS Qualifying Clinical Trial Attestation Form
252860	GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	Form	Unchanged	Qualifying Clinical Trial Preprint (Attachment 3.1-B)
252860	GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	Form	Unchanged	Qualifying Clinical Trial Preprint (Attachment 3.1-A)
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	Form and Instruction	Unchanged	Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)
252244	GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support	Form and Instruction	Unchanged	Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)
252244	GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support	Form and Instruction	Unchanged	MCO Protocol with Instructions
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	Form and Instruction	Unchanged	Monitoring Report Workbook
252106	GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	Form	Unchanged	Monitoring Report Template
252106	GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	Form and Instruction	Unchanged	Monitoring Protocol Workbook
252106	GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	Form	Unchanged	Monitoring Protocol Template
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	2022-2023 Medicaid Managed Care Rate Development Guide
251810	GenIC #37 (revision): Managed Care Rate Setting Guidance	Form and Instruction	Unchanged	2021-2022 Medicaid Managed Care Rate Development Guide
251810	GenIC #37 (revision): Managed Care Rate Setting Guidance	Form and Instruction	Unchanged
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility - Presumptive Eligibility for Pregnant Women
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility - Presumptive Eligibility for Children
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Requirements - Other Eligibility Standards (Revised)
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	General Eligibility - Eligibility Processing
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Requirements - Other Eligibility Standards
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Non-Payment of Premiums
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Substitution of Coverage
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility - Social Security Number
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility – Citizenship (Reinstatement)
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Non-Financial Eligibility – Residency
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Other Eligibility Criteria – Spenddowns
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	MAGI-Based Income Methodologies
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Deemed Newborns
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Dental Only Supplemental Coverage
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Children Who Have Access to Public Employee Coverage
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Coverage From Conception to Birth
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Targeted Low-Income Pregnant Women
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility - Targeted Low-Income Children
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged	Eligibility for Medicaid Expansion Program
251152	#17 (Revision): CHIP State Plan Eligibility	Form	Unchanged
251150	#75 (New): ARP 1135 State Plan Amendment	Form	Unchanged	Template for Medicaid Section 1135 Waiver of SPA Submission Requirements
251150	#75 (New): ARP 1135 State Plan Amendment	Form	Unchanged	Preprint Attachment 7.7C: COVID-19 Treatment
251150	#75 (New): ARP 1135 State Plan Amendment	Form	Unchanged	Preprint Attachment 7.7B: COVID-19 Testing
251150	#75 (New): ARP 1135 State Plan Amendment	Form	Unchanged	Preprint Attachment 7.7A: Vaccine and Vaccine Administration
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 and Instruction	Unchanged	Qualifying Clinical Trial Attestation Form
251149	#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	Form	Unchanged	Att. 3.1.-B (Qualifying Clinical Trial Draft Preprint)
251149	#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	Form	Unchanged	Att. 3.1-A (Qualifying Clinical Trial Draft Preprint)
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	Unchanged	Guidance Questions_Master File_PRTF
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form	Unchanged	Guidance Questions_Master File_Physician
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form	Unchanged	Guidance Questions_Master File_IMD
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form	Unchanged	Guidance Questions_Master File_ICF IID
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form	Unchanged	Guidance Questions_Master File_Clinic
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	MACFIN_prtf-upl-template
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	MACFIN_physician-upl-template
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	MACFIN_mental-disease-upl-template
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	MACFIN_intermediate-care-upl-template
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	MACFIN_clinic-services-template
251148	#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction	Unchanged	Standard Funding Questions
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	Unchanged	Guidance Questions: Outpatient
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	Unchanged	Guidance Questions: Nursing
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form	Unchanged	Guidance Questions: Inpatient
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	Unchanged	MACFIN_nursing-facility-upl-template
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	Unchanged	MACFIN_outpatient-upl-template
251147	#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction	Unchanged	MACFIN_inpatient-upl-template
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	Provider Info Mockup
250720	GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021	Form	Unchanged	Payment detail Form Mockup
250720	GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021	Form	Unchanged	SPVNarr Mockup
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 and Instruction	Unchanged	State Renewals Report
250101	GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports	Form	Unchanged	Unwinding Data Report Workbook
250101	GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports	Form	Unchanged	Screenshots: Unwinding Data Report
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	Other-Unwinding Data Report Specifications	Unchanged
249074	GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form	Unchanged	Expression of Interest Form
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	Other-Affinity Group Fact Sheet	Unchanged
248500	GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form and Instruction	Unchanged	Expression of Interest Form
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	Other-Fact Sheet	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

OMB Control No: 0938-1148	ICR Reference No: 202401-0938-016
Status: Historical Active	Previous ICR Reference No: 202103-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: [Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/31/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/30/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	04/30/2024	04/30/2024
Responses	19,623	0	6,720
Time Burden (Hours)	450,000	0	154,104
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 21 Stat. 2101
   Statute at Large: 21 Stat. 1115
   Statute at Large: 19 Stat. 1901
   Statute at Large: 19 Stat. 1915
  

Citations for New Statutory Requirements: Statute at Large: 19 Stat. 1915
Statute at Large: 21 Stat. 2101
Statute at Large: 21 Stat. 1115
Statute at Large: 19 Stat. 1901

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 37456	06/22/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 14927	03/19/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 33

table that charts list of burden

IC Title	Form No.	Form Name
#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13	MACFIN_inpatient-upl-template ,   MACFIN_outpatient-upl-template ,   MACFIN_nursing-facility-upl-template ,   Guidance Questions: Inpatient ,   Guidance Questions: Nursing ,   Guidance Questions: Outpatient
#17 (Revision): CHIP State Plan Eligibility	CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17, CMS-10398 #17	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Children ,   Eligibility - Targeted Low-Income Pregnant Women ,   Eligibility - Coverage From Conception to Birth ,   Eligibility - Children Who Have Access to Public Employee Coverage ,   Eligibility - Pregnant Women Who Have Access to Public Employee Coverage ,   Eligibility - Dental Only Supplemental Coverage ,   Eligibility - Deemed Newborns ,   Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards ,   MAGI-Based Income Methodologies ,   Other Eligibility Criteria – Spenddowns ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship (Reinstatement) ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Eligibility Processing ,   Non-Financial Requirements - Other Eligibility Standards (Revised) ,   General Eligibility - Presumptive Eligibility for Children ,   General Eligibility - Presumptive Eligibility for Pregnant Women
#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24	Standard Funding Questions ,   MACFIN_clinic-services-template ,   MACFIN_intermediate-care-upl-template ,   MACFIN_mental-disease-upl-template ,   MACFIN_physician-upl-template ,   MACFIN_prtf-upl-template ,   Guidance Questions_Master File_Clinic ,   Guidance Questions_Master File_ICF IID ,   Guidance Questions_Master File_IMD ,   Guidance Questions_Master File_Physician ,   Guidance Questions_Master File_PRTF
#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	CMS-10398 #74, CMS-10398 #74, N/A	Att. 3.1-A (Qualifying Clinical Trial Draft Preprint) ,   Att. 3.1.-B (Qualifying Clinical Trial Draft Preprint) ,   Qualifying Clinical Trial Attestation Form
#75 (New): ARP 1135 State Plan Amendment	cms-10398 #75, cms-10398 #75, cms-10398 #75, CMS-10398 #75	Preprint Attachment 7.7A: Vaccine and Vaccine Administration ,   Preprint Attachment 7.7B: COVID-19 Testing ,   Preprint Attachment 7.7C: COVID-19 Treatment ,   Template for Medicaid Section 1135 Waiver of SPA Submission Requirements
#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	CMS-10398 #79	COVID-19 Risk Corridor Reconciliation Reporting Template
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)	CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7)	CMS-10398_GenIC_7-CycleVaSAR508 ,   CMS-10398_GenIC_7-CycleVbFinalSAR508 ,   CMS-10398_GenIC_7-CycleVbMonthlyReport508 ,   CMS-10398_GenIC_7-CycleVbMonthlyReportwAIANTarget ,   CMS-10398_GenIC_7-CycleVbMonthlyReportwTarget
GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	CMS-10398. GenIC#59, CMS-10398. GenIC #59, CMS-10398. GenIC#59, CMS-10398. GenIC #59, CMS-10398. GenIC #59, CMS-10398.GenIC#59	Implementation Plan Template ,   Monitoring Report Template ,   Monitoring Report Workbook ,   Monitoring Protocol Template ,   Monitoring Protocol Workbook ,   Initial Availability Assessment
GenIC #17 (Revision): CHIP State Plan Eligibility	CS13, CS21, CS3, CS8, CS10, CS11, CS12, CS14, CS15, CS16, CS17, CS18, CS19, CS20, CS23, CS24, CS27 (Revised), CS28, CS29, CS7, CS9	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Children ,   Eligibility - Targeted Low-Income Pregnant Women ,   Eligibility - Coverage From Conception to Birth ,   Eligibility - Children Who Have Access to Public Employee Coverage ,   Eligibility - Pregnant Women Who Have Access to Public Employee Coverage ,   Eligibility - Dental Only Supplemental Coverage ,   Eligibility - Deemed Newborns ,   Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards ,   MAGI-Based Income Methodologies ,   Other Eligibility Criteria – Spenddowns ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Eligibility Processing ,   General Eligibility – Continuous Eligibility ,   General Eligibility - Presumptive Eligibility for Children ,   General Eligibility - Presumptive Eligibility for Pregnant Women
GenIC #37 (Revision): Managed Care Rate Setting Guidance
GenIC #37 (Revision): Managed Care Rate Setting Guidance
GenIC #37 (revision): Managed Care Rate Setting Guidance	CMS-10398 #37, CMS-10398 #37	2021-2022 Medicaid Managed Care Rate Development Guide ,   2022-2023 Medicaid Managed Care Rate Development Guide
GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates	CMS-10398 #57, CMS-10398 #57, CMS-10398 #57, CMS-10398 #57	Monitoring Protocol Template ,   Monitoring Protocol Workbook ,   Monitoring Report Template ,   Monitoring Report Workbook
GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Attachment 4, Attachment 5a, Attachment 7a, Attachment 5b, Attachment 7b, Attachment 8a, Attachment 8b, Attachment 11f, Attachment 12g, Attachment 12h	Implementation Plan Template ,   Monitoring Report Template ,   Monitoring Report Workbook ,   Monitoring Protocol Template ,   Monitoring Protocol Workbook ,   Initial Availability Assessment ,   Annual Availability Assessment ,   Implementation Interview Protocol with Instructions ,   IMD Interview Protocol with Instructions ,   CMHC Interview Protocol with Instruction
GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support	CMS-10398 #64, CMS-10398 $64, CMS-10398 (#64)	MCO Protocol with Instructions ,   Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers) ,   Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)
GenIC #64 (Revision): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations
GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports	CMS-10398 #66, CMS-10398 # 66, CMS-10398 #66	Screenshots: Unwinding Data Report ,   Unwinding Data Report Workbook ,   State Renewals Report
GenIC #69 (New): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID-19 Emergency
GenIC #69 (Nonsubstantive Change): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID–19 Emergency
GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment	CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7	Semi-Annual Report Template ,   Final Report Template ,   HK2019 and HK2020 Monthly Progress Report Template ,   HK2019 Monthly Progress Report with Targets Template ,   HK2022 and HK2023 Monthly Progress Report Template
GenIC #71 (New): Reporting Requirements for State Planning Grants for Qualifying Community-Based Mobile Crisis Intervention Services During the COVID–19 Emergency
GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group	CMS-10398 #72	Expression of Interest Form
GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group	CMS-10398 #72	Expression of Interest Form
GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021	CMS-64, CMS-64, CMS-64	SPVNarr Mockup ,   Payment detail Form Mockup ,   Provider Info Mockup
GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials	CMS-10398 #74, CMS-10398 #74, n/a	Qualifying Clinical Trial Preprint (Attachment 3.1-A) ,   Qualifying Clinical Trial Preprint (Attachment 3.1-B) ,   HHS Qualifying Clinical Trial Attestation Form
GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group	CMS-10398 #76	Maternal and Infant Health Initiative Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Learning Collaborative Affinity Group Expression of Interest Form
GenIC #81 (New): Improving Quality of Care and Outcomes Data for Pregnant Medicaid Beneficiaries and Newborn Infants through Linkage and Evaluation of VR, BC, DC, and TAF	CMS-10398 #81	Vital Records Data Elements - Mortality and Natality
GenIC Inventory
GenIc #37 (Revised): Medicaid Managed Care Rate Development Guide (CMS-10398)
[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	CMS-10398 #34	Title XXI State Plan Template
[Medicaid] GenIC #43 (Revised): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	CMS-10398 #43	CCBHC Cost Report
[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	CMS-10398 #45, CMS-10398 #45, CMS-10398 #45	Application and Guidance to Participate in the Section 223 CCBHC Demonstration Program ,   Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs ,   Criteria Compliance Checklist
[Medicaid] GenIC #48 (Revised): Behavioral Health Clinic Quality Data Reporting	CMS-10398 #48	Quality Measurement Data Reporting Templates

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	19,623	6,720	0	2,592	10,311	0
Annual Time Burden (Hours)	450,000	154,104	0	59,444	236,452	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: In this January 2024 iteration we propose to increase our currently approved burden ceiling (from 154,104 hr to 450,000 hr) since the ceiling has been reached by pending collection of information submissions (see GenIC #43, #45, and #48, below). The increase is needed since the current ceiling is preventing the submission of such pending collections of information as the ROCIS system will not allow the limit to be exceeded. Overall, we request an increase of 295,896 hours (450,000 hr proposed ceiling – 154,104 hr current ceiling). Of the 295,896 increase, 236,452 hours are for the pending submissions while 59,444 hours would cover upcoming unanticipated collections. Of the 154,104 hour active ceiling, 30,384 of those hours are unused (154,104 ceiling – 123,720 used) but will be added to the 59,444 figure for a total of 89,828 hours available for other upcoming collections. In sum, 450,000 hours = 23,720 hours (active) + 236,452 hours (pending, known) + 89,828 hours (unknown).

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/30/2024

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