Information Collection

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

IC 260271 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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 4 Implementation Plan Template GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 5a Monitoring Report Template GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 5b Monitoring Report Workbook GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 7a Monitoring Protocol Template GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 7b Monitoring Protocol Workbook GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 8a Initial Availability Assessment GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 8b Annual Availability Assessment GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 11f Implementation Interview Protocol with Instructions GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 12g IMD Interview Protocol with Instructions GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Form Attachment 12h CMHC Interview Protocol with Instruction GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Form and Instruction
Attachment 1. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Other-#1 Video: Overview of the Stan
Attachment 1. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Other-#1 Video: Overview of the Stan
Attachment 2. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Other-#2 Video: Populating and Submi
Attachment 2. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Other-#2 Video: Populating and Submi
Attachment 3. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Other-#3 Video: Downloading 1115 Mon
Attachment 3. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Other-#3 Video: Downloading 1115 Mon
5c - Monitoring Report Instructions (2020 version 3).pdf	Other-#5c - Monitoring Report Instru
5c - Monitoring Report Instructions (2020 version 3).pdf	Other-#5c - Monitoring Report Instru
7c - Monitoring Protocol Instructions (2020 version 3).pdf	Other-Attachment 7c - Monitoring Pro
7c - Monitoring Protocol Instructions (2020 version 3).pdf	Other-Attachment 7c - Monitoring Pro
9 - HIT Plan Instructions (2020 version 3).pdf	Other-Attachment 9 - HIT Plan Instru
9 - HIT Plan Instructions (2020 version 3).pdf	Other-Attachment 9 - HIT Plan Instru
10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf	Other-Attachment 10 - State Medicaid
10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf	Other-Attachment 10 - State Medicaid
Attachment 11.a. SMI_SED Demonstration Implementation Interview Introductory email template from CMS to state Medicaid Directors	Other-Attachment 11a - Implementatio
Attachment 11.a. SMI_SED Demonstration Implementation Interview Introductory email template from CMS to state Medicaid Directors	Other-Attachment 11a - Implementatio
Attachment 11.b. SMI_SED Demonstration Implementation Interview Email Invitation.docx	Other-Attachment 11b - Implementatio
Attachment 11.b. SMI_SED Demonstration Implementation Interview Email Invitation.docx	Other-Attachment 11b - Implementatio
Attachment 11.c. SMI_SED Demonstration Implementation Interview Confirmation Email.docx	Other-Attachment 11c - Implementatio
Attachment 11.c. SMI_SED Demonstration Implementation Interview Confirmation Email.docx	Other-Attachment 11c - Implementatio
Attachment 11.d. SMI_SED Demonstration Implementation Interview Outlook Invitation_clean.docx	Other-Attachment 11d - Implementatio
Attachment 11.d. SMI_SED Demonstration Implementation Interview Outlook Invitation_clean.docx	Other-Attachment 11d - Implementatio
Attachment 11.e. SMI_SED Demonstration Implementation Interview Reminder email.docx	Other-Attachment 11e - Implementatio
Attachment 11.e. SMI_SED Demonstration Implementation Interview Reminder email.docx	Other-Attachment 11e - Implementatio
Attachment 11.g. SMI_SED Demonstration Implementation Interview Thank you email.docx	Other-Attachment 11g - Implementatio
Attachment 11.g. SMI_SED Demonstration Implementation Interview Thank you email.docx	Other-Attachment 11g - Implementatio
Attachment 12.a. IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director_508.docx	Other-Attachment 12a - IMD and CMHC
Attachment 12.a. IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director_508.docx	Other-Attachment 12a - IMD and CMHC
Attachment 12.b. IMD-CMHC Interview Introductory Email from RTI to SMD_Clean_508.docx	Other-Attachment 12b - IMD and CMHC
Attachment 12.b. IMD-CMHC Interview Introductory Email from RTI to SMD_Clean_508.docx	Other-Attachment 12b - IMD and CMHC
Attachment 12.c. IMD-CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director_Clean_508.docx	Other-Attachment 12c - IMD and CMHC
Attachment 12.c. IMD-CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director_Clean_508.docx	Other-Attachment 12c - IMD and CMHC
Attachment 12.d. IMD and CMHC Provider Interview Email Invitation_clean_508.docx	Other-Attachment 12d - IMD and CMHC
Attachment 12.d. IMD and CMHC Provider Interview Email Invitation_clean_508.docx	Other-Attachment 12d - IMD and CMHC
Attachment 12.e. IMD and CMHC Provider Stakeholder Interview Outlook Invitation_Clean_508.docx	Other-Attachments 12e - IMD and CMHC
Attachment 12.e. IMD and CMHC Provider Stakeholder Interview Outlook Invitation_Clean_508.docx	Other-Attachments 12e - IMD and CMHC
Attachment 12.f. IMD and CMHC Provider Stakeholder Interview Confirmation Email_Clean_508.docx	Other-Attachment 12f - IMD and CMHC
Attachment 12.f. IMD and CMHC Provider Stakeholder Interview Confirmation Email_Clean_508.docx	Other-Attachment 12f - IMD and CMHC
Attachment 12.i. IMD and CMHC Provider Stakeholder Interview Thank You Email_Clean_508.docx	Other-Attachment 12i - IMD and CMHC
Attachment 12.i. IMD and CMHC Provider Stakeholder Interview Thank You Email_Clean_508.docx	Other-Attachment 12i - IMD and CMHC
6 - Monitoring Metrics Technical Specifications (2020 version 3) (1).pdf	Other-Attachment 6: Technical Specif
6 - Monitoring Metrics Technical Specifications (2020 version 3) (1).pdf	Other-Attachment 6: Technical Specif
Attachment 4 Implementation Plan Template Attachment 4. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx	Form and Instruction
Attachment 4 Implementation Plan Template Attachment 4. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx	Form and Instruction
Attachment 5a Monitoring Report Template Attachment 5a. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx	Form and Instruction
Attachment 5a Monitoring Report Template Attachment 5a. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx	Form and Instruction
Attachment 5b Monitoring Report Workbook Attachment 5b. The Medicaid Section 1115 SMISED Monitoring WorkbookPlanned Metrics_Clean.xlsx	Form and Instruction
Attachment 5b Monitoring Report Workbook Attachment 5b. The Medicaid Section 1115 SMISED Monitoring WorkbookPlanned Metrics_Clean.xlsx	Form and Instruction
Attachment 7a Monitoring Protocol Template Attachment 7a. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx	Form and Instruction
Attachment 7a Monitoring Protocol Template Attachment 7a. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx	Form and Instruction
Attachment 7b Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx	Form and Instruction
Attachment 7b Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx	Form and Instruction
Attachment 8a Initial Availability Assessment Attachment 8a - Initial Availability Assessment_Clean.xlsm	Form and Instruction
Attachment 8a Initial Availability Assessment Attachment 8a - Initial Availability Assessment_Clean.xlsm	Form and Instruction
Attachment 8b Annual Availability Assessment Attachment 8b - Annual Availability Assessment_Clean.xlsm	Form and Instruction
Attachment 8b Annual Availability Assessment Attachment 8b - Annual Availability Assessment_Clean.xlsm	Form and Instruction
Attachment 11f Implementation Interview Protocol with Instructions Attachment 11.f. SMI_SED Demonstration Implementstion Interview Protocol.docx	Form and Instruction
Attachment 11f Implementation Interview Protocol with Instructions Attachment 11.f. SMI_SED Demonstration Implementstion Interview Protocol.docx	Form and Instruction
Attachment 12g IMD Interview Protocol with Instructions Attachment 12.g. IMD Interview Protocol with Instructions_Clean_508.docx	Form and Instruction
Attachment 12g IMD Interview Protocol with Instructions Attachment 12.g. IMD Interview Protocol with Instructions_Clean_508.docx	Form and Instruction
Attachment 12h CMHC Interview Protocol with Instruction Attachment 12.h. CMHC Interview Protocol with Instruction_Clean_508.docx	Form and Instruction
Attachment 12h CMHC Interview Protocol with Instruction Attachment 12.h. CMHC Interview Protocol with Instruction_Clean_508.docx	Form and Instruction
GenIC #59 - Generic Supporting Statement (2023 version 11).docx Generic Supporting Statement	IC Document
GenIC #59 - Generic Supporting Statement (2023 version 11).docx Generic Supporting Statement	IC Document
lhp-vdfz-msa3 - Combined Cover Note and Comment.pdf Public Comment (page 1 of 3)	IC Document
lhp-vdfz-msa3 - Combined Cover Note and Comment.pdf Public Comment (page 1 of 3)	IC Document
lhp-vdfz-msa3 - Conceptualization Stage of Research.pdf Public Comment (page 2 of 3)	IC Document
lhp-vdfz-msa3 - Conceptualization Stage of Research.pdf Public Comment (page 2 of 3)	IC Document
lhp-vdfz-msa3 - Stress,Emotion, and Mental Health in African American Men- Final Draft.pdf Public Comment (page 3 of 3)	IC Document
lhp-vdfz-msa3 - Stress,Emotion, and Mental Health in African American Men- Final Draft.pdf Public Comment (page 3 of 3)	IC Document
Response To Public Comments.docx Response to Public Comments	IC Document
Response To Public Comments.docx Response to Public Comments	IC Document
Crosswalk - Attachment 5b Monitoring Report Workbook.xlsx Crosswalk - Attachment 5b Monitoring Report Workbook	IC Document
Crosswalk - Attachment 5b Monitoring Report Workbook.xlsx Crosswalk - Attachment 5b Monitoring Report Workbook	IC Document
Crosswalk - Attachment 7b Monitoring Protocol Workbook.xlsx Crosswalk Attachment 7b - Monitoring Protocol Workbook	IC Document
Crosswalk - Attachment 7b Monitoring Protocol Workbook.xlsx Crosswalk Attachment 7b - Monitoring Protocol Workbook	IC Document
Crosswalk - Attachment 8b Annual Availability Assessment.xlsx Crosswalk - Attachment 8b Annual Availability Assessment	IC Document
Crosswalk - Attachment 8b Annual Availability Assessment.xlsx Crosswalk - Attachment 8b Annual Availability Assessment	IC Document
Crosswalk - Attachment 4 Implementation Plan Template.xlsx Crosswalk: Attachment 4 - Implementation Plan Template	IC Document
Crosswalk - Attachment 4 Implementation Plan Template.xlsx Crosswalk: Attachment 4 - Implementation Plan Template	IC Document
Crosswalk - Attachment 5a Monitoring Report Template.xlsx Crosswalk: Attachment 5a - Monitoring Report Template.xlsx	IC Document
Crosswalk - Attachment 5a Monitoring Report Template.xlsx Crosswalk: Attachment 5a - Monitoring Report Template.xlsx	IC Document
Crosswalk - Attachment 7a Monitoring Protocol Template.xlsx Crosswalk: Attachment 7a - Monitoring Protocol Template.xlsx	IC Document
Crosswalk - Attachment 7a Monitoring Protocol Template.xlsx Crosswalk: Attachment 7a - Monitoring Protocol Template.xlsx	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: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-#1 Video: Overview of the Standardized Monitoring Report Process		https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Yes	No	Printable Only
Other-#2 Video: Populating and Submitting Monitoring Templates		https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Yes	No	Printable Only
Other-#3 Video: Downloading 1115 Monitoring Report Templates		https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Yes	No	Printable Only
Form and Instruction	Attachment 4		Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 5a		Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 5b		Yes	Yes	Fillable Fileable
Other-#5c - Monitoring Report Instructions			Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 7a		Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 7b		Yes	Yes	Fillable Fileable
Other-Attachment 7c - Monitoring Protocol Instructions			Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 8a		Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 8b		Yes	Yes	Fillable Fileable
Other-Attachment 9 - HIT Plan Instructions			Yes	Yes	Fillable Fileable
Other-Attachment 10 - State Medicaid Directors letter (SMDL) #18-011			No		Printable Only
Other-Attachment 11a - Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director			Yes	Yes	Fillable Fileable
Other-Attachment 11b - Implementation Interview Email Invitation			Yes	Yes	Fillable Fileable
Other-Attachment 11c - Implementation Interview Confirmation Email			Yes	Yes	Fillable Fileable
Other-Attachment 11d - Implementation Interview Outlook Invitation			Yes	Yes	Fillable Fileable
Other-Attachment 11e - Implementation Interview Reminder Email			Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 11f		Yes	Yes	Fillable Fileable
Other-Attachment 11g - Implementation Interview Thank You Email			Yes	Yes	Fillable Fileable
Other-Attachment 12a - IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director			Yes	Yes	Fillable Fileable
Other-Attachment 12b - IMD and CMHC Provider Stakeholder Interview Introductory Email from RTI to State Medicaid Director			Yes	Yes	Fillable Fileable
Other-Attachment 12c - IMD and CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director			Yes	Yes	Fillable Fileable
Other-Attachment 12d - IMD and CMHC Provider Stakeholder Interview Email Invitation			Yes	Yes	Fillable Fileable
Other-Attachments 12e - IMD and CMHC Provider Stakeholder Interview Outlook Invitation			Yes	Yes	Fillable Fileable
Other-Attachment 12f - IMD and CMHC Provider Stakeholder Interview Confirmation Email			Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 12g		Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 12h		Yes	Yes	Fillable Fileable
Other-Attachment 12i - IMD and CMHC Provider Stakeholder Interview Thank You Email			Yes	Yes	Fillable Fileable
Other-Attachment 6: Technical Specifications for Monitoring Metrics			No		Printable Only

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: 65

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	168	168
Annual IC Time Burden (Hours)	1,708	1,708
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		05/23/2023
Public Comment (page 1 of 3)		05/18/2023
Public Comment (page 2 of 3)		05/18/2023
Public Comment (page 3 of 3)		05/18/2023
Response to Public Comments		05/18/2023
Crosswalk - Attachment 5b Monitoring Report Workbook		05/22/2023
Crosswalk Attachment 7b - Monitoring Protocol Workbook		05/22/2023
Crosswalk - Attachment 8b Annual Availability Assessment		05/22/2023
Crosswalk: Attachment 4 - Implementation Plan Template		05/23/2023
Crosswalk: Attachment 5a - Monitoring Report Template.xlsx		05/23/2023
Crosswalk: Attachment 7a - Monitoring Protocol Template.xlsx		05/23/2023

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

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