Information Collection

GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports

IC 250101 under ICR 202401-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports	Form
Form CMS-10398 #66 GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports	Form
#66 - Unwinding Data Report specifications (2022 version 4).pdf	Other-Unwinding Data Report Specific
#66 - Unwinding Data Report specifications (2022 version 4).pdf	Other-Unwinding Data Report Specific
CMS-10398 #66 Screenshots: Unwinding Data Report #66 - Unwinding Data Report screen shots (2022 version 1).pdf	Form
CMS-10398 #66 Screenshots: Unwinding Data Report #66 - Unwinding Data Report screen shots (2022 version 1).pdf	Form
CMS-10398 # 66 Unwinding Data Report Workbook #66 Unwinding Data Report excel workbook (2022 version 3).xlsx	Form
CMS-10398 # 66 Unwinding Data Report Workbook #66 Unwinding Data Report excel workbook (2022 version 3).xlsx	Form
CMS-10398 #66 State Renewals Report #66 State Renewals Report (2022 version 3).docx	Form and Instruction
CMS-10398 #66 State Renewals Report #66 State Renewals Report (2022 version 3).docx	Form and Instruction
SHO Letter 21002 August 2021.pdf SHO letter 21002 August 2021	IC Document
SHO Letter 21002 August 2021.pdf SHO letter 21002 August 2021	IC Document
Placeholder - SHO Letter 2200X March 2022.docx Placeholder: SHO letter 2200X March 2022	IC Document
Placeholder - SHO Letter 2200X March 2022.docx Placeholder: SHO letter 2200X March 2022	IC Document
#66 - Generic Supporting Statement (2022 version 6).docx Generic Supporting Statement	IC Document
#66 - Generic Supporting Statement (2022 version 6).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #66	Screenshots: Unwinding Data Report	#66 - Unwinding Data Report screen shots (2022 version 1).pdf	Yes	Yes	Fillable Fileable
Other-Unwinding Data Report Specifications			#66 - Unwinding Data Report specifications (2022 version 4).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 # 66	Unwinding Data Report Workbook	#66 Unwinding Data Report excel workbook (2022 version 3).xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #66	State Renewals Report	#66 State Renewals Report (2022 version 3).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	896	896
Annual IC Time Burden (Hours)	14,224	14,224
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SHO letter 21002 August 2021	SHO Letter 21002 August 2021.pdf	02/28/2022
Placeholder: SHO letter 2200X March 2022	Placeholder - SHO Letter 2200X March 2022.docx	02/28/2022
Generic Supporting Statement	#66 - Generic Supporting Statement (2022 version 6).docx	02/28/2022

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