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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.

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

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

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   100 %

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

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.