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Federal forms, ICRs, and supporting documents

Information Collection

GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support

IC 252244 under ICR 202401-0938-016 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Attachment 3.a. MCO-BH Administrator Interview Introductory Email to SMD from CMS.pdf Other-Introductory Email (from CMS t
Attachment 3.a. MCO-BH Administrator Interview Introductory Email to SMD from CMS.pdf Other-Introductory Email (from CMS t
Attachment 3.b. MCO-BH Administrator Interview Introductory Email to SMD from RTI_DDME.pdf Other-Introductory Email (from RTI t
Attachment 3.b. MCO-BH Administrator Interview Introductory Email to SMD from RTI_DDME.pdf Other-Introductory Email (from RTI t
Attachment 3.c. MCO.BH Administrator Introductory Email from SMD.pdf Other-Introductory Email (from State
Attachment 3.c. MCO.BH Administrator Introductory Email from SMD.pdf Other-Introductory Email (from State
Attachment 3.d. MCO-BH Administrator Interview Introductory Email.pdf Other-Interview Email Invitation
Attachment 3.d. MCO-BH Administrator Interview Introductory Email.pdf Other-Interview Email Invitation
Attachment 3.e. MCO.BH Administrator Interview Outlook Invitation_clean.pdf Other-Interview Outlook Invitation
Attachment 3.e. MCO.BH Administrator Interview Outlook Invitation_clean.pdf Other-Interview Outlook Invitation
Attachment 3.f. MCO.BH Administrator Interview Confirmation Email_clean.pdf Other-Interview Confirmation Email
Attachment 3.f. MCO.BH Administrator Interview Confirmation Email_clean.pdf Other-Interview Confirmation Email
Attachment 3.j. MCO.BH Administrator.Thank you note .pdf Other-Thank You Email
Attachment 3.j. MCO.BH Administrator.Thank you note .pdf Other-Thank You Email
CMS-10398 #64 MCO Protocol with Instructions
Attachment 3.g. OMB.MCO_interview_protocol_CMSComments_RTI_CLEAN2_12.14.21.pdf 		Form and Instruction
CMS-10398 #64 MCO Protocol with Instructions
Attachment 3.g. OMB.MCO_interview_protocol_CMSComments_RTI_CLEAN2_12.14.21.pdf 		Form and Instruction
CMS-10398 $64 Behavioral Health Stakeholder Interview Protocol with In
Attachment 3.h. OMB.BH_interview_residential_protocol_CMSComments_RTI_clean_12.14.21.pdf 		Form and Instruction
CMS-10398 $64 Behavioral Health Stakeholder Interview Protocol with In
Attachment 3.h. OMB.BH_interview_residential_protocol_CMSComments_RTI_clean_12.14.21.pdf 		Form and Instruction
CMS-10398 (#64) Behavioral Health Stakeholder Interview Protocol with In
Attachment 3.i. OMB.BH_interview_NONresidential_protocol_CMSComments_RTI_clean_12.14.21.pdf 		Form and Instruction
CMS-10398 (#64) Behavioral Health Stakeholder Interview Protocol with In
Attachment 3.i. OMB.BH_interview_NONresidential_protocol_CMSComments_RTI_clean_12.14.21.pdf 		Form and Instruction
64 - Generic Supporting Statement (2022 version 6).docx
Generic Supporting Statement		IC Document
64 - Generic Supporting Statement (2022 version 6).docx
Generic Supporting Statement		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Introductory Email (from CMS to State Medicaid Director) Attachment 3.a. MCO-BH Administrator Interview Introductory Email to SMD from CMS.pdf Yes Yes Fillable Fileable
Other-Introductory Email (from RTI to State Medicaid Director) Attachment 3.b. MCO-BH Administrator Interview Introductory Email to SMD from RTI_DDME.pdf Yes Yes Fillable Fileable
Other-Introductory Email (from State Medicaid Director) Attachment 3.c. MCO.BH Administrator Introductory Email from SMD.pdf Yes Yes Fillable Fileable
Other-Interview Email Invitation Attachment 3.d. MCO-BH Administrator Interview Introductory Email.pdf Yes Yes Fillable Fileable
Other-Interview Outlook Invitation Attachment 3.e. MCO.BH Administrator Interview Outlook Invitation_clean.pdf Yes Yes Fillable Fileable
Other-Interview Confirmation Email Attachment 3.f. MCO.BH Administrator Interview Confirmation Email_clean.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #64 MCO Protocol with Instructions Attachment 3.g. OMB.MCO_interview_protocol_CMSComments_RTI_CLEAN2_12.14.21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10398 $64 Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers) Attachment 3.h. OMB.BH_interview_residential_protocol_CMSComments_RTI_clean_12.14.21.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10398 (#64) Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers) Attachment 3.i. OMB.BH_interview_NONresidential_protocol_CMSComments_RTI_clean_12.14.21.pdf Yes Yes Fillable Fileable
Other-Thank You Email Attachment 3.j. MCO.BH Administrator.Thank you note .pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 90 0 0 0 0 90
Annual IC Time Burden (Hours) 5 0 0 0 0 5
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Generic Supporting Statement 64 - Generic Supporting Statement (2022 version 6).docx 03/18/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.