Emergency Reinstatement

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

04/26/2024

Department of Health and Human Services
Centers for Medicare & Medicaid Services
FOR CERTIFYING OFFICIAL:

Jennifer Wendel

FOR CLEARANCE OFFICER:

Susan Little

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
04/02/2024
ACTION REQUESTED: Generic IC
GenIC #81 (New): Improving Quality of Care and Outcomes Data for Pregnant Medicaid
IC TITLE:
Beneficiaries and Newborn Infants through Linkage and Evaluation of VR, BC, DC, and TAF
ICR REFERENCE NUMBER:
202401-0938-016
AGENCY ICR TRACKING NUMBER:

CMCS

TITLE:

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions
(CMS-10398)
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

0938-1148

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 04/30/2024

BURDEN:

DISCONTINUE DATE:

RESPONSES

HOURS

COSTS

6,720

154,104

0

19,623

450,000

0

0

0

0

Change due to Agency Discretion

2,592

59,444

0

Change due to Agency Adjustment

10,311

236,452

0

0

0

0

Previous
New
Difference
Change due to New Statute

Change due to PRA Violation
TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Deputy Administrator,
Office Of Information And Regulatory Affairs

IC Title

Form No.

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

GenIC Inventory

79,962 / 0 / 6,720

GenIC #69 (New):
Reporting
Requirements for
Additional Funding for
Medicaid HCBS During
the COVID-19
Emergency
GenIc #37 (Revised):
Medicaid Managed
Care Rate Development
Guide (CMS-10398)
GenIC #71 (New):
Reporting
Requirements for State
Planning Grants for
Qualifying CommunityBased Mobile Crisis
Intervention Services
During the COVID–19
Emergency
GenIC #69
(Nonsubstantive
Change): Reporting
Requirements for
Additional Funding for
Medicaid HCBS During
the COVID–19
Emergency
GenIC #72 (New):
CMS-10398 #72
Expressions of Interest
in the Infant Well-Child
Visit Affinity Group
GenIC #72
CMS-10398 #72
(Nonsubstantive
Change): Expressions
of Interest in the Infant
Well-Child Visit Affinity
Group
GenIC #66 (New):
CMS-10398 #66, CMSMedicaid and CHIP
10398 #66, CMS-10398
COVID 19 Public Health # 66
Emergency Unwinding
Reports
GenIC #73 (New):
CMS-64, CMS-64,
Supplemental Payment CMS-64
Reporting under the
Consolidated
Appropriations Act,
2021
#13 (Revision):
CMS-10398 #13, CMSMedicaid Accountability 10398 #13, CMS-10398
– Nursing Facility,
#13, CMS-10398 #13,
Outpatient Hospital and CMS-10398 #13, CMSInpatient Hospital Upper 10398 #13
Payment Limits

1,344 / 0 / 616

5 / 0 / 135

640 / 0 / 160

5 / 0 / 616

Expression of Interest
Form

140 / 0 / 20

Expression of Interest
Form

5 / 0 / 20

Screenshots: Unwinding
Data Report, State
Renewals Report,
Unwinding Data Report
Workbook
SPVNarr Mockup,
Provider Info Mockup ,
Payment detail Form
Mockup

14,224 / 0 / 896

MACFIN_outpatient-upltemplate,
MACFIN_inpatient-upltemplate, Guidance
Questions: Outpatient,
MACFIN_nursing-facilityupl-template, Guidance
Questions: Inpatient,
Guidance Questions:
Nursing

5 / 0 / 54

3,240 / 0 / 216

IC Title

Form No.

#24 (Revision):
Medicaid Accountability
– Upper Payment Limits
for Clinics, Physician
Services, ICF/IID,
PRTFs, and IMDs

CMS-10398 #24, CMS10398 #24, CMS-10398
#24, CMS-10398 #24,
CMS-10398 #24, CMS10398 #24, CMS-10398
#24, CMS-10398 #24,
CMS-10398 #24, CMS10398 #24, CMS-10398
#24

List of ICs
Form Name

Guidance
Questions_Master
File_ICF IID, Guidance
Questions_Master
File_IMD, Guidance
Questions_Master
File_Physician, Guidance
Questions_Master
File_PRTF,
MACFIN_physician-upltemplate,
MACFIN_mental-diseaseupl-template,
MACFIN_intermediatecare-upl-template,
MACFIN_clinic-servicestemplate, Standard
Funding Questions,
Guidance
Questions_Master
File_Clinic, MACFIN_prtfupl-template
#74 (New): Coverage of CMS-10398 #74, CMS- Att. 3.1.-B (Qualifying
Routine Patient Cost for 10398 #74, N/A
Clinical Trial Draft
Items & Services in
Preprint), Att. 3.1-A
Qualifying Clinical Trials
(Qualifying Clinical Trial
Draft Preprint), Qualifying
Clinical Trial Attestation
Form
#75 (New): ARP 1135 cms-10398 #75, CMS- Preprint Attachment 7.7C:
State Plan Amendment 10398 #75, cms-10398 COVID-19 Treatment ,
#75, cms-10398 #75
Template for Medicaid
Section 1135 Waiver of
SPA Submission
Requirements, Preprint
Attachment 7.7B: COVID19 Testing , Preprint
Attachment 7.7A: Vaccine
and Vaccine
Administration

CFR Citation

Hrs/$/Resp
5 / 0 / 54

61 / 0 / 66

168 / 0 / 56

IC Title
#17 (Revision): CHIP
State Plan Eligibility

Form No.
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17

List of ICs
Form Name

Eligibility - Targeted LowIncome Children, NonFinancial Requirements Other Eligibility Standards
(Revised), Eligibility Coverage From
Conception to Birth,
Eligibility - Children Who
Have Access to Public
Employee Coverage,
Eligibility - Pregnant
Women Who Have
Access to Public
Employee Coverage,
Eligibility - Dental Only
Supplemental Coverage,
Eligibility - Deemed
Newborns, Eligibility Children Ineligible for
Medicaid as a Result of
the Elimination of Income
Disregards, MAGI-Based
Income Methodologies,
Other Eligibility Criteria –
Spenddowns, NonFinancial Eligibility –
Citizenship
(Reinstatement), NonFinancial Eligibility - Social
Security Number, NonFinancial Eligibility Substitution of Coverage,
Non-Financial Eligibility Non-Payment of
Premiums, Non-Financial
Eligibility – Residency,
Non-Financial
Requirements - Other
Eligibility Standards,
General Eligibility Eligibility Processing,
Eligibility for Medicaid
Expansion Program,
General Eligibility Presumptive Eligibility for
Pregnant Women,
General Eligibility Presumptive Eligibility for
Children, Eligibility Targeted Low-Income
Pregnant Women
GenIC #37 (revision):
CMS-10398 #37, CMS- 2022-2023 Medicaid
Managed Care Rate
10398 #37
Managed Care Rate
Setting Guidance
Development Guide,
2021-2022 Medicaid
Managed Care Rate
Development Guide
GenIC #57 (Revision): CMS-10398 #57, CMS- Monitoring Protocol
Medicaid Section 1115 10398 #57, CMS-10398 Template, Monitoring
Substance Use
#57, CMS-10398 #57 Protocol Workbook,
Disorder (SUD)
Monitoring Report
Demonstration:
Template, Monitoring
Monitoring Reports
Report Workbook
Documents and
Templates

CFR Citation

Hrs/$/Resp
5 / 0 / 56

5 / 0 / 135

5 / 0 / 596

IC Title

Form No.

List of ICs
Form Name

Hrs/$/Resp

GenIC #64 (Revision) CMS-10398 #64, CMSMedicaid Section 1115 10398 $64, CMS-10398
Substance Use
(#64)
Disorder (SUD)
Demonstrations:
Federal Meta-Analysis
Support

5 / 0 / 90

GenIC #74 (Revised):
Coverage of Routine
Patient Cost for Items &
Services in Qualifying
Clinical Trials

5 / 0 / 66

GenIC #76 (New):
Expressions of Interest
in the Improving
Maternal Health by
Reducing Low-Risk
Cesarean Delivery
Affinity Group
GenIC # 59 (Revision) Medicaid Section 1115
Severe Mental Illness
and Children with
Serious Emotional
Disturbance
Demonstrations
CHIPRA Connecting
Kids to Coverage
Outreach and
Enrollment Grants
(CMS-10398; GenIC
#7)

GenIC #7 (Revision):
Connecting Kids to
Coverage Outreach and
Enrollment

#79 (New): COVID-19
Risk Corridor
Reconciliation
Reporting Template
GenIC #37 (Revision):
Managed Care Rate
Setting Guidance

MCO Protocol with
Instructions, Behavioral
Health Stakeholder
Interview Protocol with
Instructions (Residential
Providers), Behavioral
Health Stakeholder
Interview Protocol with
Instructions (NonResidential Providers)
CMS-10398 #74, CMS- Qualifying Clinical Trial
10398 #74, n/a
Preprint (Attachment 3.1B), Qualifying Clinical Trial
Preprint (Attachment 3.1A), HHS Qualifying
Clinical Trial Attestation
Form
CMS-10398 #76
Maternal and Infant Health
Initiative Improving
Maternal Health by
Reducing Low-Risk
Cesarean Delivery
Learning Collaborative
Affinity Group Expression
of Interest Form
CMS-10398. GenIC#59, Monitoring Protocol
CMS-10398. GenIC
Template, Implementation
#59, CMS-10398.
Plan Template, Monitoring
GenIC#59, CMS-10398. Report Template,
GenIC #59, CMSMonitoring Report
10398. GenIC #59,
Workbook , Monitoring
CMS-10398.GenIC#59 Protocol Workbook , Initial
Availability Assessment
CMS-10398 (GenIC#7), CMS-10398_GenIC_7CMS-10398 (GenIC#7), CycleVaSAR508, CMSCMS-10398 (GenIC#7), 10398_GenIC_7CMS-10398 (GenIC#7), CycleVbFinalSAR508,
CMS-10398 (GenIC#7) CMS-10398_GenIC_7CycleVbMonthlyReport50
8, CMS-10398_GenIC_7CycleVbMonthlyReportwA
IANTarget, CMS10398_GenIC_7CycleVbMonthlyReportwT
arget
CMS-10398 #7, CMS- HK2022 and HK2023
10398 #7, CMS-10398 Monthly Progress Report
#7, CMS-10398 #7,
Template, HK2019
CMS-10398 #7
Monthly Progress Report
with Targets Template,
HK2019 and HK2020
Monthly Progress Report
Template, Semi-Annual
Report Template, Final
Report Template
CMS-10398 #79
COVID-19 Risk Corridor
Reconciliation Reporting
Template

CFR Citation

140 / 0 / 20

3,314 / 0 / 114

10,102 / 0 / 1,973

7,826 / 0 / 1,365

90 / 0 / 30

135 / 0 / 135

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

Form No.
Attachment 4,
Attachment 5a,
Attachment 5b,
Attachment 7a,
Attachment 7b,
Attachment 8a,
Attachment 8b,
Attachment 11f,
Attachment 12g,
Attachment 12h

GenIC #64 (Revision):
Federal Meta-Analysis
Support: Section 1115
Substance Use
Disorder
Demonstrations
[Medicaid] GenIC #34 CMS-10398 #34
(Revised): Model
Application Template
and Instructions for
State Child Health Plan
Under Title XXI of the
Social Security Act,
State Children's Health
Insurance Program

List of ICs
Form Name
Implementation Plan
Template, Monitoring
Report Template,
Monitoring Report
Workbook, Monitoring
Protocol Template,
Monitoring Protocol
Workbook, Initial
Availability Assessment,
Annual Availability
Assessment,
Implementation Interview
Protocol with Instructions,
IMD Interview Protocol
with Instructions, CMHC
Interview Protocol with
Instruction

CFR Citation

Hrs/$/Resp
1,708 / 0 / 168

405 / 0 / 340

Title XXI State Plan
Template

160 / 0 / 40

IC Title
GenIC #17 (Revision):
CHIP State Plan
Eligibility

GenIC #37 (Revision):
Managed Care Rate
Setting Guidance
[Medicaid] GenIC #48
(Revised): Behavioral
Health Clinic Quality
Data Reporting
[Medicaid] GenIC #45
(Revised): Certified
Community Behavioral
Health Clinic (CCBHC)
2024 State Proposal
Demonstration
Application

Form No.
CS8, CS10, CS11,
CS12, CS14, CS15,
CS16, CS17, CS18,
CS19, CS20, CS23,
CS24, CS27 (Revised),
CS28, CS29, CS7,
CS9, CS13, CS21, CS3

List of ICs
Form Name
Eligibility - Targeted LowIncome Pregnant Women,
Eligibility - Children Who
Have Access to Public
Employee Coverage,
Eligibility - Pregnant
Women Who Have
Access to Public
Employee Coverage,
Eligibility - Dental Only
Supplemental Coverage,
Eligibility - Children
Ineligible for Medicaid as
a Result of the Elimination
of Income Disregards,
MAGI-Based Income
Methodologies, Other
Eligibility Criteria –
Spenddowns, NonFinancial Eligibility –
Residency, Non-Financial
Eligibility – Citizenship,
Non-Financial Eligibility Social Security Number,
Non-Financial Eligibility Substitution of Coverage,
Non-Financial
Requirements - Other
Eligibility Standards,
General Eligibility Eligibility Processing,
General Eligibility –
Continuous Eligibility,
General Eligibility Presumptive Eligibility for
Children, General
Eligibility - Presumptive
Eligibility for Pregnant
Women, Eligibility Targeted Low-Income
Children, Eligibility Coverage From
Conception to Birth,
Eligibility - Deemed
Newborns, Non-Financial
Eligibility - Non-Payment
of Premiums, Eligibility for
Medicaid Expansion
Program

CFR Citation

Hrs/$/Resp
5 / 0 / 56

11 / 0 / 2
CMS-10398 #48

Quality Measurement
Data Reporting Templates

CMS-10398 #45, CMS- Guidance on Addition of
10398 #45, CMS-10398 CCBHCs to Section 223
#45
State Demonstration
Programs, Criteria
Compliance Checklist,
Application and Guidance
to Participate in the
Section 223 CCBHC
Demonstration Program

231,272 / 0 / 1,009

1,790 / 0 / 30

IC Title

Form No.

List of ICs
Form Name

CFR Citation

[Medicaid] GenIC #43 CMS-10398 #43
CCBHC Cost Report
(Revised): Certified
Community Behavioral
Health Clinic (CCBHC)
Cost Report
GenIC #81 (New):
CMS-10398 #81
Vital Records Data
Improving Quality of
Elements - Mortality and
Care and Outcomes
Natality
Data for Pregnant
Medicaid Beneficiaries
and Newborn Infants
through Linkage and
Evaluation of VR, BC,
DC, and TAF
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
3,390 / 0 / 60

104 / 0 / 104

360,281