Information Collection

[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application

IC 264851 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⚠️ Notice: This information collection may be referencing outdated material.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 #45 [Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction
CMS-10398 #45 Application and Guidance to Participate in the Section 2 2024 CCBHC Demonstration Application- Fillable.pdf	Form and Instruction
CMS-10398 #45 Guidance on Addition of CCBHCs to Section 223 State Demo Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs (SAMHSA OAS Approved).pdf	Form and Instruction
CMS-10398 #45 Criteria Compliance Checklist Criteria Compliance Checklist-State (6-28-23-SAMHSA OAS Approved).pdf	Form and Instruction
GenIC #45 - Generic Supporting Statement (2023 version 9).docx Generic Supporting Statement	IC Document
45 - CCBHC Demonstration Application- CMS SAMHSA Updates REDLINES 1-30-24 (004).docx Track Change: Demonstration Application	IC Document
Demonstration Application Changes Crosswalk_CMS and SAMHSA 1-29-24_508.pdf Crosswalk: Demonstration Application	IC Document
#45 CCBHC State Propoal Application_PRA Comment Responses 02-01-2024.pdf Response to Public Comments	IC Document
lrp-ej3s-43jw - Comment.pdf Public Comment 43jw (National Council for Mental Wellbeing)	IC Document
lrp-gu9v-ya9i - Cover Info and Comment.pdf Public Comment ya9i (affiliate.dhhs.nh.gov)	IC Document
lrp-i3cc-afry - Cover Info and Comment.pdf Public Comment afry (healthmanagement.com)	IC Document
lrq-i6xj-a3nh - Cover Info and Comment.pdf Public Comment a3nh (Myers and Stauffer, LC)	IC Document
lrq-t2w5-z9dd - Cover Info and Comment.pdf Public Comment z9dd	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #45	Application and Guidance to Participate in the Section 223 CCBHC Demonstration Program	2024 CCBHC Demonstration Application- Fillable.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #45	Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs	Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs (SAMHSA OAS Approved).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #45	Criteria Compliance Checklist	Criteria Compliance Checklist-State (6-28-23-SAMHSA OAS Approved).pdf	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: 30

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	1,790	1,790
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	GenIC #45 - Generic Supporting Statement (2023 version 9).docx	02/01/2024
Track Change: Demonstration Application	45 - CCBHC Demonstration Application- CMS SAMHSA Updates REDLINES 1-30-24 (004).docx	02/01/2024
Crosswalk: Demonstration Application	Demonstration Application Changes Crosswalk_CMS and SAMHSA 1-29-24_508.pdf	02/01/2024
Response to Public Comments	#45 CCBHC State Propoal Application_PRA Comment Responses 02-01-2024.pdf	02/01/2024
Public Comment 43jw (National Council for Mental Wellbeing)	lrp-ej3s-43jw - Comment.pdf	02/01/2024
Public Comment ya9i (affiliate.dhhs.nh.gov)	lrp-gu9v-ya9i - Cover Info and Comment.pdf	02/01/2024
Public Comment afry (healthmanagement.com)	lrp-i3cc-afry - Cover Info and Comment.pdf	02/01/2024
Public Comment a3nh (Myers and Stauffer, LC)	lrq-i6xj-a3nh - Cover Info and Comment.pdf	02/01/2024
Public Comment z9dd	lrq-t2w5-z9dd - Cover Info and Comment.pdf	02/01/2024

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