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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.

Documents and Forms
Document Name
Document Type
Other-#1 Video: Overview of the Stan
Other-#1 Video: Overview of the Stan
Other-#2 Video: Populating and Submi
Other-#2 Video: Populating and Submi
Other-#3 Video: Downloading 1115 Mon
Other-#3 Video: Downloading 1115 Mon
Other-#5c - Monitoring Report Instru
Other-#5c - Monitoring Report Instru
Other-Attachment 7c - Monitoring Pro
Other-Attachment 7c - Monitoring Pro
Other-Attachment 9 - HIT Plan Instru
Other-Attachment 9 - HIT Plan Instru
Other-Attachment 10 - State Medicaid
Other-Attachment 10 - State Medicaid
Other-Attachment 11a - Implementatio
Other-Attachment 11a - Implementatio
Other-Attachment 11b - Implementatio
Other-Attachment 11b - Implementatio
Other-Attachment 11c - Implementatio
Other-Attachment 11c - Implementatio
Other-Attachment 11d - Implementatio
Other-Attachment 11d - Implementatio
Other-Attachment 11e - Implementatio
Other-Attachment 11e - Implementatio
Other-Attachment 11g - Implementatio
Other-Attachment 11g - Implementatio
Other-Attachment 12a - IMD and CMHC
Other-Attachment 12a - IMD and CMHC
Other-Attachment 12b - IMD and CMHC
Other-Attachment 12b - IMD and CMHC
Other-Attachment 12c - IMD and CMHC
Other-Attachment 12c - IMD and CMHC
Other-Attachment 12d - IMD and CMHC
Other-Attachment 12d - IMD and CMHC
Other-Attachments 12e - IMD and CMHC
Other-Attachments 12e - IMD and CMHC
Other-Attachment 12f - IMD and CMHC
Other-Attachment 12f - IMD and CMHC
Other-Attachment 12i - IMD and CMHC
Other-Attachment 12i - IMD and CMHC
Other-Attachment 6: Technical Specif
Other-Attachment 6: Technical Specif
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-#1 Video: Overview of the Standardized Monitoring Report Process Attachment 1. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ Yes No Printable Only
Other-#2 Video: Populating and Submitting Monitoring Templates Attachment 2. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ Yes No Printable Only
Other-#3 Video: Downloading 1115 Monitoring Report Templates Attachment 3. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ Yes No Printable Only
Form and Instruction Attachment 4 Implementation Plan Template Attachment 4. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 5a Monitoring Report Template Attachment 5a. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 5b Monitoring Report Workbook Attachment 5b. The Medicaid Section 1115 SMISED Monitoring WorkbookPlanned Metrics_Clean.xlsx Yes Yes Fillable Fileable
Other-#5c - Monitoring Report Instructions 5c - Monitoring Report Instructions (2020 version 3).pdf Yes Yes Fillable Fileable
Form and Instruction Attachment 7a Monitoring Protocol Template Attachment 7a. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 7b Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx Yes Yes Fillable Fileable
Other-Attachment 7c - Monitoring Protocol Instructions 7c - Monitoring Protocol Instructions (2020 version 3).pdf Yes Yes Fillable Fileable
Form and Instruction Attachment 8a Initial Availability Assessment Attachment 8a - Initial Availability Assessment_Clean.xlsm Yes Yes Fillable Fileable
Form and Instruction Attachment 8b Annual Availability Assessment Attachment 8b - Annual Availability Assessment_Clean.xlsm Yes Yes Fillable Fileable
Other-Attachment 9 - HIT Plan Instructions 9 - HIT Plan Instructions (2020 version 3).pdf Yes Yes Fillable Fileable
Other-Attachment 10 - State Medicaid Directors letter (SMDL) #18-011 10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf No   Printable Only
Other-Attachment 11a - Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director Attachment 11.a. SMI_SED Demonstration Implementation Interview Introductory email template from CMS to state Medicaid Directors.docx Yes Yes Fillable Fileable
Other-Attachment 11b - Implementation Interview Email Invitation Attachment 11.b. SMI_SED Demonstration Implementation Interview Email Invitation.docx Yes Yes Fillable Fileable
Other-Attachment 11c - Implementation Interview Confirmation Email Attachment 11.c. SMI_SED Demonstration Implementation Interview Confirmation Email.docx Yes Yes Fillable Fileable
Other-Attachment 11d - Implementation Interview Outlook Invitation Attachment 11.d. SMI_SED Demonstration Implementation Interview Outlook Invitation_clean.docx Yes Yes Fillable Fileable
Other-Attachment 11e - Implementation Interview Reminder Email Attachment 11.e. SMI_SED Demonstration Implementation Interview Reminder email.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 11f Implementation Interview Protocol with Instructions Attachment 11.f. SMI_SED Demonstration Implementstion Interview Protocol.docx Yes Yes Fillable Fileable
Other-Attachment 11g - Implementation Interview Thank You Email Attachment 11.g. SMI_SED Demonstration Implementation Interview Thank you email.docx Yes Yes Fillable Fileable
Other-Attachment 12a - IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director Attachment 12.a. IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director_508.docx Yes Yes Fillable Fileable
Other-Attachment 12b - IMD and CMHC Provider Stakeholder Interview Introductory Email from RTI to State Medicaid Director Attachment 12.b. IMD-CMHC Interview Introductory Email from RTI to SMD_Clean_508.docx Yes Yes Fillable Fileable
Other-Attachment 12c - IMD and CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director Attachment 12.c. IMD-CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director_Clean_508.docx Yes Yes Fillable Fileable
Other-Attachment 12d - IMD and CMHC Provider Stakeholder Interview Email Invitation Attachment 12.d. IMD and CMHC Provider Interview Email Invitation_clean_508.docx Yes Yes Fillable Fileable
Other-Attachments 12e - IMD and CMHC Provider Stakeholder Interview Outlook Invitation Attachment 12.e. IMD and CMHC Provider Stakeholder Interview Outlook Invitation_Clean_508.docx Yes Yes Fillable Fileable
Other-Attachment 12f - IMD and CMHC Provider Stakeholder Interview Confirmation Email Attachment 12.f. IMD and CMHC Provider Stakeholder Interview Confirmation Email_Clean_508.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 12g IMD Interview Protocol with Instructions Attachment 12.g. IMD Interview Protocol with Instructions_Clean_508.docx Yes Yes Fillable Fileable
Form and Instruction Attachment 12h CMHC Interview Protocol with Instruction Attachment 12.h. CMHC Interview Protocol with Instruction_Clean_508.docx Yes Yes Fillable Fileable
Other-Attachment 12i - IMD and CMHC Provider Stakeholder Interview Thank You Email Attachment 12.i. IMD and CMHC Provider Stakeholder Interview Thank You Email_Clean_508.docx Yes Yes Fillable Fileable
Other-Attachment 6: Technical Specifications for Monitoring Metrics 6 - Monitoring Metrics Technical Specifications (2020 version 3) (1).pdf No   Printable Only

Health Health Care Services

 

65 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 168 0 0 0 0 168
Annual IC Time Burden (Hours) 1,708 0 0 0 0 1,708
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC #59 - Generic Supporting Statement (2023 version 11).docx 05/23/2023
Public Comment (page 1 of 3) lhp-vdfz-msa3 - Combined Cover Note and Comment.pdf 05/18/2023
Public Comment (page 2 of 3) lhp-vdfz-msa3 - Conceptualization Stage of Research.pdf 05/18/2023
Public Comment (page 3 of 3) lhp-vdfz-msa3 - Stress,Emotion, and Mental Health in African American Men- Final Draft.pdf 05/18/2023
Response to Public Comments Response To Public Comments.docx 05/18/2023
Crosswalk - Attachment 5b Monitoring Report Workbook Crosswalk - Attachment 5b Monitoring Report Workbook.xlsx 05/22/2023
Crosswalk Attachment 7b - Monitoring Protocol Workbook Crosswalk - Attachment 7b Monitoring Protocol Workbook.xlsx 05/22/2023
Crosswalk - Attachment 8b Annual Availability Assessment Crosswalk - Attachment 8b Annual Availability Assessment.xlsx 05/22/2023
Crosswalk: Attachment 4 - Implementation Plan Template Crosswalk - Attachment 4 Implementation Plan Template.xlsx 05/23/2023
Crosswalk: Attachment 5a - Monitoring Report Template.xlsx Crosswalk - Attachment 5a Monitoring Report Template.xlsx 05/23/2023
Crosswalk: Attachment 7a - Monitoring Protocol Template.xlsx 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.