Information Collection

GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

IC 253727 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⚠️ Notice: This information collection may be referencing outdated material.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. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form
Form CMS-10398. GenIC # GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form
5c - Monitoring Report Instructions (2020 version 3).pdf	Instruction
5c - Monitoring Report Instructions (2020 version 3).pdf	Instruction
6 - Monitoring Metrics Technical Specifications (2020 version 3).pdf	Instruction
6 - Monitoring Metrics Technical Specifications (2020 version 3).pdf	Instruction
7c - Monitoring Protocol Instructions (2020 version 3).pdf	Instruction
7c - Monitoring Protocol Instructions (2020 version 3).pdf	Instruction
9 - HIT Plan Instructions (2020 version 3).pdf	Instruction
9 - HIT Plan Instructions (2020 version 3).pdf	Instruction
10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf	Instruction
10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf	Instruction
Video 1 - Overview of the Standardized Monitoring Report Process.pdf cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Instruction
Video 1 - Overview of the Standardized Monitoring Report Process.pdf cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Instruction
Video 2 - Populating and Submitting Monitoring Templates.pdf cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Instruction
Video 2 - Populating and Submitting Monitoring Templates.pdf cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Instruction
Video 3 - Downloading 1115 Monitoring Report Templates.pdf cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
Video 3 - Downloading 1115 Monitoring Report Templates.pdf cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
CMS-10398. GenIC # Implementation Plan Template 4 - Implementation Plan Template (2020 version 3).pdf	Form
CMS-10398. GenIC # Implementation Plan Template 4 - Implementation Plan Template (2020 version 3).pdf	Form
CMS-10398. GenIC#5 Monitoring Report Template 5a - Monitoring Report Template (2020 version 3).docx	Form
CMS-10398. GenIC#5 Monitoring Report Template 5a - Monitoring Report Template (2020 version 3).docx	Form
CMS-10398. GenIC # Monitoring Report Workbook 5b - Monitoring Report Workbook (2020 version 3).xlsm	Form and Instruction
CMS-10398. GenIC # Monitoring Report Workbook 5b - Monitoring Report Workbook (2020 version 3).xlsm	Form and Instruction
CMS-10398. GenIC#5 Monitoring Protocol Template 7a - Monitoring Protocol Template (2020 version 3).docx	Form
CMS-10398. GenIC#5 Monitoring Protocol Template 7a - Monitoring Protocol Template (2020 version 3).docx	Form
CMS-10398. GenIC # Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx	Form
CMS-10398. GenIC # Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx	Form
CMS-10398.GenIC#59 Initial Availability Assessment 8 - Initial Availability Assessment (2020 version 3).xlsm	Form and Instruction
CMS-10398.GenIC#59 Initial Availability Assessment 8 - Initial Availability Assessment (2020 version 3).xlsm	Form and Instruction
GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22).docx GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22)	IC Document
GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22).docx GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22)	IC Document
Attachment 11.a - g. SMI _SED Demonstration Implementation Docs.pdf Attachment 11.a - g. SMI _SED Demonstration Implementation Docs	IC Document
Attachment 11.a - g. SMI _SED Demonstration Implementation Docs.pdf Attachment 11.a - g. SMI _SED Demonstration Implementation Docs	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

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
Form	CMS-10398. GenIC #59	Implementation Plan Template	4 - Implementation Plan Template (2020 version 3).pdf		Yes	Yes	Fillable Fileable
Form	CMS-10398. GenIC#59	Monitoring Report Template	5a - Monitoring Report Template (2020 version 3).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398. GenIC #59	Monitoring Report Workbook	5b - Monitoring Report Workbook (2020 version 3).xlsm		Yes	Yes	Fillable Fileable
Instruction			5c - Monitoring Report Instructions (2020 version 3).pdf		Yes	Yes	Printable Only
Instruction			6 - Monitoring Metrics Technical Specifications (2020 version 3).pdf		Yes	Yes	Printable Only
Form	CMS-10398. GenIC#59	Monitoring Protocol Template	7a - Monitoring Protocol Template (2020 version 3).docx		Yes	Yes	Fillable Fileable
Form	CMS-10398. GenIC #59	Monitoring Protocol Workbook	7b - Monitoring Protocol Workbook (2020 version 3).xlsx		Yes	Yes	Fillable Fileable
Instruction			7c - Monitoring Protocol Instructions (2020 version 3).pdf		Yes	Yes	Printable Only
Form and Instruction	CMS-10398.GenIC#59	Initial Availability Assessment	8 - Initial Availability Assessment (2020 version 3).xlsm		Yes	Yes	Fillable Fileable
Instruction			9 - HIT Plan Instructions (2020 version 3).pdf		Yes	Yes	Printable Only
Instruction			10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf		Yes	Yes	Printable Only
Instruction			Video 1 - Overview of the Standardized Monitoring Report Process.pdf	https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Yes	Yes	Fillable Fileable
Instruction			Video 2 - Populating and Submitting Monitoring Templates.pdf	https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Yes	Yes	Fillable Fileable
Instruction			Video 3 - Downloading 1115 Monitoring Report Templates.pdf	https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	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: 10

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	114	114
Annual IC Time Burden (Hours)	3,314	3,314
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22)	GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22).docx	05/19/2022
Attachment 11.a - g. SMI _SED Demonstration Implementation Docs	Attachment 11.a - g. SMI _SED Demonstration Implementation Docs.pdf	05/19/2022

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