[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Attachment 3 Connecting Kids to Coverage Final Report	Form and Instruction	New	Repair queued
Form Attachment 2 Connecting Kids to Coverage Semi-Annual Progress Report	Form and Instruction	New	Repair queued
Form Attachment 1 Connecting Kids to Coverage Monthly Progress Report	Form and Instruction	New	Repair queued
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries	Form	New	Repair queued
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	New	Repair queued
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form	New	Repair queued
Form CS27 General Eligibility – Continuous Eligibility	Form	New	Repair queued
Form CS24 General Eligibility - Eligibility Processing	Form	New	Repair queued
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form	New	Repair queued
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form	New	Repair queued
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form	New	Repair queued
Form CS19 Non-Financial Eligibility - Social Security Number	Form	New	Repair queued
Form CS18 Non-Financial Eligibility – Citizenship	Form	New	Repair queued
Form CS17 Non-Financial Eligibility – Residency	Form	New	Repair queued
Form CS16 Other Eligibility Criteria – Spenddowns	Form	New	Repair queued
Form CS15 MAGI-Based Income Methodologies	Form	New	Repair queued
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	New	Repair queued
Form CS13 Eligibility - Deemed Newborns	Form	New	Repair queued
Form CS12 Eligibility for Dental Only Supplemental Coverage	Form	New	Repair queued
Form CS11 Eligibility for Pregnant Women Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS10 Eligibility for Children Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS9 Eligibility for Coverage From Conception to Birth	Form	New	Repair queued
Form CS8 Eligibility for Targeted Low-Income Pregnant Women	Form	New	Repair queued
Form CS7 Eligibility for Targeted Low-Income Children	Form	New	Repair queued
Form CS3 Eligibility for Medicaid Expansion Program	Form	New	Repair queued
Form CMS-10398 #96 State Summary Template	Form and Instruction	New	Repair queued
Form CMS-10398 #96 State Fee-for-Service (FFS) Program Reporting Template	Form and Instruction	New	Repair queued
Form CMS-10398 #96 Health Plan Reporting Template	Form and Instruction	New	Repair queued
Form 13g Follow-up Implementation Interview Thank You Email	Form	New	Repair queued
Form 13f Follow-up Implementation Interview Protocol with Instructions	Form and Instruction	New	Repair queued
Form 13e Follow-up Implementation Interview Reminder Email	Form	New	Repair queued
Form 13d Follow-up Implementation Interview Outlook Invitation	Form	New	Repair queued
Form 13c Follow-up Implementation Interview Confirmation Email	Form	New	Repair queued
Form 13b Follow-up Implementation Interview Email Invitation	Form	New	Repair queued
Form 13a Follow-up Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director	Form	New	Repair queued
Form 12i Provider Interview Thank You Email	Form	New	Repair queued
Form 12h CMHC Interview Protocol with Instructions	Form and Instruction	New	Repair queued
Form 12g IMD Interview Protocol with Instructions	Form and Instruction	New	Repair queued
Form 12f Provider Interview Confirmation Email	Form	New	Repair queued
Form 12e Provider Interview Outlook Invitation	Form	New	Repair queued
Form 12d Provider Interview Email Invitation	Form	New	Repair queued
Form 12c Provider Interview Introductory Email from State Medicaid Director	Form	New	Repair queued
Form 12b Provider Interview Introductory Email from RTI to State Medicaid Director	Form	New	Repair queued
Form 12a Provider Interview Introductory Email from CMS to State Medicaid Director	Form	New	Repair queued
Form 11g Initial Implementation Interview Thank You Email	Form	New	Repair queued
Form 11f Initial Implementation Interview Protocol with Instructions	Form and Instruction	New	Repair queued
Form 11e Initial Implementation Interview Reminder Email	Form	New	Repair queued
Form 11d Initial Implementation Interview Outlook Invitation	Form	New	Repair queued
Form 11c Initial Implementation Interview Confirmation Email	Form	New	Repair queued
Form 11b Initial Implementation Interview Email Invitation	Form	New	Repair queued
Form 11a Initial Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director	Form	New	Repair queued
Form 8a Initial Availability Assessment	Form	New	Repair queued
Form 8b Annual Availability Assessment	Form	New	Repair queued
Form 7b Monitoring Protocol Workbook	Form	New	Repair queued
Form 7a Monitoring Protocol Template	Form	New	Repair queued
Form 5b Monitoring Report Workbook	Form	New	Repair queued
Form 5a Monitoring Report Template	Form	New	Repair queued
Form 4 Implementation Plan Template	Form	New	Repair queued
Form GenIC #45 Compliance Checklist	Form and Instruction	New	Repair queued
Form GenIC #45 Demonstration Application	Form and Instruction	New	Repair queued
Form CMS-10398 #43 CCBHC Cost Report	Form	New	Repair queued
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries	Form	New	Repair queued
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	New	Repair queued
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form	New	Repair queued
Form CS27 General Eligibility – Continuous Eligibility	Form	New	Repair queued
Form CS24 General Eligibility - Eligibility Processing	Form	New	Repair queued
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form	New	Repair queued
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form	New	Repair queued
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form	New	Repair queued
Form CS19 Non-Financial Eligibility - Social Security Number	Form	New	Repair queued
Form CS18 Non-Financial Eligibility – Citizenship	Form	New	Repair queued
Form CS17 Non-Financial Eligibility – Residency	Form	New	Repair queued
Form CS16 Other Eligibility Criteria – Spenddowns	Form	New	Repair queued
Form CS15 MAGI-Based Income Methodologies	Form	New	Repair queued
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	New	Repair queued
Form CS13 Eligibility - Deemed Newborns	Form	New	Repair queued
Form CS12 Eligibility - Dental Only Supplemental Coverage	Form	New	Repair queued
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS9 Eligibility - Coverage From Conception to Birth	Form	New	Repair queued
Form CS8 Eligibility - Targeted Low-Income Pregnant Women	Form	New	Repair queued
Form CS7 Eligibility - Targeted Low-Income Children	Form	New	Repair queued
Form CS3 Eligibility for Medicaid Expansion Program	Form	New	Repair queued
Form 4g Follow-Up Implementation Interview Thank You Email	Form	New	Repair queued
Form 4f Follow-Up Implementation Interview Protocol with Instructions	Form and Instruction	New	Repair queued
Form 4e Follow-Up Implementation Interview Reminder Email	Form	New	Repair queued
Form 4d Follow-Up Implementation Interview Outlook Invitation	Form	New	Repair queued
Form 4c Follow-Up Implementation Interview Confirmation Email	Form	New	Repair queued
Form 4b Follow-Up Implementation Interview Email Invitation	Form	New	Repair queued
Form 4a Follow-Up Implementation Interview Introductory Email	Form	New	Repair queued
Form 3j MCO and Behavioral Health Provider Stakeholder Interview Thank You Email	Form	New	Repair queued
Form 3i Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)	Form and Instruction	New	Repair queued
Form 3h Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)	Form and Instruction	New	Repair queued
Form 3g MCO Protocol with Instructions	Form and Instruction	New	Repair queued
Form 3f MCO and Behavioral Health Provider Stakeholder Interview Confirmation Email	Form	New	Repair queued
Form 3e MCO and Behavioral Health Provider Stakeholder Interview Outlook Invitation	Form	New	Repair queued
Form 3d MCO and Behavioral Health Provider Stakeholder Interview Email Invitation	Form	New	Repair queued
Form 3c MCO and Behavioral Health Provider Stakeholder Interview Introductory Email	Form	New	Repair queued
Form 3b MCO and Behavioral Health Provider Stakeholder Interview Introductory Email	Form	New	Repair queued
Form 3a MCO and Behavioral Health Stakeholder Interview Introductory Email	Form	New	Repair queued
Form 1g Characteristics/Implementation Interview Thank You Email	Form	New	Repair queued
Form 1f Characteristics/Implementation Interview Reminder Email	Form	New	Repair queued
Form 1e Characteristics/Implementation Interview Invitation	Form	New	Repair queued
Form 1d Characteristics/Implementation Confirmation Email	Form	New	Repair queued
Form 1c Interview Questions	Form and Instruction	New	Repair queued
Form 1b Characteristics/Implementation Interview Email Invitation with Program Characteristics Grid	Form	New	Repair queued
Form 1a Characteristics/Implementation Introductory Email	Form	New	Repair queued
Form GenIC #56 State User Budget Neutrality Playbook	Form and Instruction	New	Repair queued
Form GenIC #56 PMDA Budget Neutrality Monitoring Workbook	Form and Instruction	New	Repair queued
Form GenIC #94 Intake Form	Form and Instruction	New	Repair queued
Form GenIC #94 MES Project Status Report	Form and Instruction	New	Repair queued
Form GenIC #94 Operational Report Workbook	Form and Instruction	New	Repair queued
Form GenIC #94 MES RFP Checklist	Form and Instruction	New	Repair queued
Form GenIC #94 MES MDBT+CHIP Template	Form and Instruction	New	Repair queued
Form GenIC #94 AoA Template	Form and Instruction	New	Repair queued
Form GenIC #94 MES OAPD Template	Form and Instruction	New	Repair queued
Form GenIC #94 MES APD Template	Form and Instruction	New	Repair queued
Form CMS-10398 #68 SPA Attachment 3.1: Section 1905(a)(29) Medication Assisted Treatment (MAT)	Form	New	Repair queued
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries	Form	New	Repair queued
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	New	Repair queued
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form	New	Repair queued
Form CS27 General Eligibility – Continuous Eligibility	Form	New	Repair queued
Form CS24 General Eligibility - Eligibility Processing	Form	New	Repair queued
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form	New	Repair queued
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form	New	Repair queued
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form	New	Repair queued
Form CS19 Non-Financial Eligibility - Social Security Number	Form	New	Repair queued
Form CS18 Non-Financial Eligibility – Citizenship	Form	New	Repair queued
Form CS17 Non-Financial Eligibility – Residency	Form	New	Repair queued
Form CS16 Other Eligibility Criteria – Spenddowns	Form	New	Repair queued
Form CS15 MAGI-Based Income Methodologies	Form	New	Repair queued
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	New	Repair queued
Form CS13 Eligibility - Deemed Newborns	Form	New	Repair queued
Form CS12 Eligibility - Dental Only Supplemental Coverage	Form	New	Repair queued
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage	Form	New	Repair queued
Form CS9 Eligibility - Coverage From Conception to Birth	Form	New	Repair queued
Form CS8 Eligibility - Targeted Low-Income Pregnant Women	Form	New	Repair queued
Form CS7 Eligibility - Targeted Low-Income Children	Form	New	Repair queued
Form CS3 Eligibility for Medicaid Expansion Program	Form	New	Repair queued
Form CMS-10398 #93 Attachment 3.1-L-SUD/IMD (SPA Templates)	Form	New	Repair queued
Form CMS-10398 #87 Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template	Form and Instruction	New	Repair queued
Form Supplement to Atta State Plan Amendment (SPA) Template for Medicaid Clinic Benefit	Form	New	Repair queued
Form Appendix B PACE AWOP & Rate Package Submission Cover Sheet	Form	New	Repair queued
Form #83 PACE SPA Preprint	Form	New	Repair queued
Form GenIC #86 Reentry Budget Neutrality Formulation Workbook	Form and Instruction	New	Repair queued
Form GenIC #86 Reentry Implementation Plan Template	Form and Instruction	New	Repair queued
Form GenIC #86 Reentry Demonstration Initiative Preprint	Form	New	Repair queued
Form CMS-10398 #88 SBS Grant Data Submission and TAC Participation Form	Form and Instruction	New	Repair queued
Form Supplement to Atta Targeted Case Management (TCM) for Mandatory Coverage of Eligible Juveniles	Form	New	Repair queued
Form Attachment 3.1-M p Attestation for Optional Coverage of Eligible Juveniles	Form	New	Repair queued
Form Attachment 3.1-M p Attestation for Mandatory Coverage of Eligible Juveniles	Form	New	Repair queued
Form GenIC #82 Quality Improvement Affinity Group Expression of Interest Form	Form and Instruction	New	Available
Form GenIC #82 GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form	Form and Instruction	New	Available
Form GenIC #66 Eligibility Processing Data Report excel workbook	Form and Instruction	New	Available
Form GenIC #66 Eligibility Processing Data Report portal screen shots	Form and Instruction	New	Available
Form GenIC #66 Compliance Assessment and Plan for Federal Medicaid and CHIP Renewal Requirements Template	Form and Instruction	New	Available
Form Misc (see spreadsh Misc (see spreadsheet)	Form and Instruction	New	Repair queued
Form Misc (see spreadsh Reinstatement of Previously Approved GenICs	Form and Instruction	New	Repair queued
CMS-10398.30-day FRN (89 FR 68619) 8-27-24.pdf	Supplementary Document	Uploaded 2024-09-27	Repair queued
CMS-10398.60-day FRN (89 FR 50333) 6-13-24.pdf	Supplementary Document	Uploaded 2024-09-27	Repair queued
lzr-8frk-fajr - Comment (CMS-10398 #79).pdf	Public Comments	Uploaded 2024-08-12	Repair queued
lzq-fmf9-sr5n - Comment (CMS-10398 #57).pdf	Public Comments	Uploaded 2024-08-11	Repair queued
lzg-02aa-qsnt - Comment (CMS-10398 #43).pdf	Public Comments	Uploaded 2024-08-04	Repair queued
Response to Public Comments.docx	Supplementary Document	Uploaded 2024-09-27	Repair queued
Response to Public Comments.docx	Supplementary Document	Uploaded 2024-09-27	Repair queued
CMS-10398 - Supporting Statement A (2024 version 6).docx	Supporting Statement A	Uploaded 2024-09-27	Repair queued
CMS-10398 - Supporting Statement A (2024 version 6).docx	Supporting Statement A	Uploaded 2024-09-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
281464	[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment	Form and Instruction	New	Connecting Kids to Coverage Final Report
281464	[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment	Form and Instruction	New	Connecting Kids to Coverage Semi-Annual Progress Report
281464	[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment	Form and Instruction	New	Connecting Kids to Coverage Monthly Progress Report
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	General Eligibility - Incarcerated CHIP Beneficiaries
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Pregnant Women
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Children
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	General Eligibility – Continuous Eligibility
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	General Eligibility - Eligibility Processing
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Requirements - Other Eligibility Standards
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Non-Payment of Premiums
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Substitution of Coverage
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Social Security Number
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Citizenship
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Residency
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Other Eligibility Criteria – Spenddowns
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	MAGI-Based Income Methodologies
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility - Deemed Newborns
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Dental Only Supplemental Coverage
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Pregnant Women Who Have Access to Public Employee Coverage
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Children Who Have Access to Public Employee Coverage
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Coverage From Conception to Birth
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Targeted Low-Income Pregnant Women
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Targeted Low-Income Children
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Form	New	Eligibility for Medicaid Expansion Program
280367	[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	Instruction	New
280051	[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools	Form and Instruction	New	State Summary Template
280051	[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools	Form and Instruction	New	State Fee-for-Service (FFS) Program Reporting Template
280051	[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools	Form and Instruction	New	Health Plan Reporting Template
280051	[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools	Instruction	New
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Thank You Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form and Instruction	New	Follow-up Implementation Interview Protocol with Instructions
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Reminder Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Outlook Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Confirmation Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Email Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Follow-up Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Thank You Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form and Instruction	New	CMHC Interview Protocol with Instructions
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form and Instruction	New	IMD Interview Protocol with Instructions
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Confirmation Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Outlook Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Email Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Introductory Email from State Medicaid Director
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Introductory Email from RTI to State Medicaid Director
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Provider Interview Introductory Email from CMS to State Medicaid Director
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Thank You Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form and Instruction	New	Initial Implementation Interview Protocol with Instructions
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Reminder Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Outlook Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Confirmation Email
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Email Invitation
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Initial Availability Assessment
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Annual Availability Assessment
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Monitoring Protocol Workbook
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Monitoring Protocol Template
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Monitoring Report Workbook
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Monitoring Report Template
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Form	New	Implementation Plan Template
279189	[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	Other-Video: Overview of the Standardized Monitoring Report Proc	New
279184	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction	New	Compliance Checklist
279184	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Form and Instruction	New	Demonstration Application
279184	[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	Other-Guidance on Addition of CCBHCs	New
279018	[Medicaid] GenIC #43 (Revision): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	Form	New	CCBHC Cost Report
279018	[Medicaid] GenIC #43 (Revision): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	Instruction	New
278912	[Medicaid] GenIC #37 (Revised) Medicaid Managed Care Rate Development Guide	Instruction	New
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	General Eligibility - Incarcerated CHIP Beneficiaries
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Pregnant Women
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Children
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	General Eligibility – Continuous Eligibility
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	General Eligibility - Eligibility Processing
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Requirements - Other Eligibility Standards
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Non-Payment of Premiums
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Substitution of Coverage
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Social Security Number
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Citizenship
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Residency
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Other Eligibility Criteria – Spenddowns
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	MAGI-Based Income Methodologies
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Deemed Newborns
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Dental Only Supplemental Coverage
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Children Who Have Access to Public Employee Coverage
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Coverage From Conception to Birth
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Targeted Low-Income Pregnant Women
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility - Targeted Low-Income Children
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Form	New	Eligibility for Medicaid Expansion Program
278850	[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	Instruction	New
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Thank You Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form and Instruction	New	Follow-Up Implementation Interview Protocol with Instructions
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Reminder Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Outlook Invitation
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Confirmation Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Email Invitation
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Follow-Up Implementation Interview Introductory Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Thank You Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form and Instruction	New	Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form and Instruction	New	Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form and Instruction	New	MCO Protocol with Instructions
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Confirmation Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Outlook Invitation
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Email Invitation
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Introductory Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Provider Stakeholder Interview Introductory Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	MCO and Behavioral Health Stakeholder Interview Introductory Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Interview Thank You Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Interview Reminder Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Interview Invitation
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Confirmation Email
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form and Instruction	New	Interview Questions
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Interview Email Invitation with Program Characteristics Grid
277992	[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	Form	New	Characteristics/Implementation Introductory Email
277663	[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	Form and Instruction	New	State User Budget Neutrality Playbook
277663	[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	Form and Instruction	New	PMDA Budget Neutrality Monitoring Workbook
277663	[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	Instruction	New
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	Intake Form
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	MES Project Status Report
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	Operational Report Workbook
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	MES RFP Checklist
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	MES MDBT+CHIP Template
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	AoA Template
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	MES OAPD Template
276836	[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	Form and Instruction	New	MES APD Template
276243	[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)	Form	New	SPA Attachment 3.1: Section 1905(a)(29) Medication Assisted Treatment (MAT)
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	General Eligibility - Incarcerated CHIP Beneficiaries
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Pregnant Women
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	General Eligibility - Presumptive Eligibility for Children
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	General Eligibility – Continuous Eligibility
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	General Eligibility - Eligibility Processing
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Requirements - Other Eligibility Standards
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Non-Payment of Premiums
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Substitution of Coverage
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility - Social Security Number
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Citizenship
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Non-Financial Eligibility – Residency
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Other Eligibility Criteria – Spenddowns
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	MAGI-Based Income Methodologies
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Deemed Newborns
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Dental Only Supplemental Coverage
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Children Who Have Access to Public Employee Coverage
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Coverage From Conception to Birth
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Targeted Low-Income Pregnant Women
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility - Targeted Low-Income Children
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	New	Eligibility for Medicaid Expansion Program
276172	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Other-Introduction to the IG	New
276021	GenIC #93 (New): Medicaid 1915(l) State Plan Option to Provide Medical Assistance for Eligible Individuals Who Are Patients in Eligible Institutions for Mental Diseases	Form	New	Attachment 3.1-L-SUD/IMD (SPA Templates)
276013	GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template	Form and Instruction	New	Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template
275989	[Medicaid] GenIC #37 (Revised): Medicaid Managed Care Rate Development Guide	Other-2024-2025 Rate Guide	New
274252	[Medicaid] GenIC #91 (New): State Plan Amendment (SPA) Template for Medicaid Clinic Benefit	Form	New	State Plan Amendment (SPA) Template for Medicaid Clinic Benefit
273912	[Medicaid] GenIC #90 (New): CAA of 2024, Section 206 Planning Grant Reporting	Instruction	New
273876	[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide	Form	New	PACE AWOP & Rate Package Submission Cover Sheet
273876	[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide	Instruction	New
273457	[Medicaid] GenIC #83 (New) PACE SPA Preprint	Form	New	PACE SPA Preprint
273188	[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative	Form and Instruction	New	Reentry Budget Neutrality Formulation Workbook
273188	[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative	Form and Instruction	New	Reentry Implementation Plan Template
273188	[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative	Form	New	Reentry Demonstration Initiative Preprint
273188	[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative	Instruction	New
272791	[Medicaid] GenIC #88 (New): Medicaid/CHIP School-Based Services (SBS) Grants	Form and Instruction	New	SBS Grant Data Submission and TAC Participation Form
272763	GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form	New	Targeted Case Management (TCM) for Mandatory Coverage of Eligible Juveniles
272763	GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form	New	Attestation for Optional Coverage of Eligible Juveniles
272763	GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form	New	Attestation for Mandatory Coverage of Eligible Juveniles
271243	GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form	Form and Instruction	New	Quality Improvement Affinity Group Expression of Interest Form
271243	GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form	Form and Instruction	New
271239	GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template	Form and Instruction	New	Eligibility Processing Data Report excel workbook
271239	GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template	Form and Instruction	New	Eligibility Processing Data Report portal screen shots
271239	GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template	Form and Instruction	New	Compliance Assessment and Plan for Federal Medicaid and CHIP Renewal Requirements Template
271239	GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template	Other-Data Specifications	New
271238	Reinstatement of Previously Approved GenICs	Form and Instruction	New	Misc (see spreadsheet)
271238	Reinstatement of Previously Approved GenICs	Form and Instruction	New

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 202409-0938-028
Status: Historical Active	Previous ICR Reference No: 202401-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: [Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/03/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/27/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency the agency will submit individual collections under this generic clearance for approval. CMS should consider the timeliness of steps required to continue this collection before the end of this three year OMB approval. This information collection replaces the collections covered under emergency collection (CMS-10398, OMB 0938-1148) which will be discontinued shortly to prevent duplication.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2027	36 Months From Approved
Responses	19,623	0	0
Time Burden (Hours)	450,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 21 Stat. 2101
   Statute at Large: 21 Stat. 1115
   Statute at Large: 19 Stat. 1901
   Statute at Large: 19 Stat. 1915
  

Citations for New Statutory Requirements: Statute at Large: 19 Stat. 1915
Statute at Large: 21 Stat. 2101
Statute at Large: 21 Stat. 1115
Statute at Large: 19 Stat. 1901

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 50333	06/13/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 68619	08/27/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 26

table that charts list of burden

IC Title	Form No.	Form Name
GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template	GenIC #66, GenIC #66, GenIC #66	Compliance Assessment and Plan for Federal Medicaid and CHIP Renewal Requirements Template ,   Eligibility Processing Data Report portal screen shots ,   Eligibility Processing Data Report excel workbook
GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form	GenIC #82	Quality Improvement Affinity Group Expression of Interest Form
GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Attachment 3.1-M pages 1 and 2, Attachment 3.1-M page 3, Supplement to Attachment 3.1	Attestation for Mandatory Coverage of Eligible Juveniles ,   Attestation for Optional Coverage of Eligible Juveniles ,   Targeted Case Management (TCM) for Mandatory Coverage of Eligible Juveniles
GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template	CMS-10398 #87	Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template
GenIC #93 (New): Medicaid 1915(l) State Plan Option to Provide Medical Assistance for Eligible Individuals Who Are Patients in Eligible Institutions for Mental Diseases	CMS-10398 #93	Attachment 3.1-L-SUD/IMD (SPA Templates)
Reinstatement of Previously Approved GenICs	Misc (see spreadsheet)	Misc (see spreadsheet)
[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	GenIC #56, GenIC #56	PMDA Budget Neutrality Monitoring Workbook ,   State User Budget Neutrality Playbook
[Medicaid] GenIC #17 (Revised) CHIP State Plan Eligibility	CS3, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14, CS15, CS29, CS31, CS16, CS17, CS18, CS19 , CS20, CS21, CS23, CS24, CS27, CS28	Eligibility for Medicaid Expansion Program ,   Eligibility for Targeted Low-Income Children ,   Eligibility for Targeted Low-Income Pregnant Women ,   Eligibility for Coverage From Conception to Birth ,   Eligibility for Children Who Have Access to Public Employee Coverage ,   Eligibility for Pregnant Women Who Have Access to Public Employee Coverage ,   Eligibility for 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 ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   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 ,   General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	CS18, CS19, CS23, CS24, CS20, CS27, CS28, CS29, CS31, CS21, CS17, CS15, CS11, CS3, CS7, CS8, CS9, CS10, CS12, CS13, CS14, CS16	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Children ,   Eligibility - Targeted Low-Income Pregnant Women ,   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 ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   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 ,   General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility	CS9, CS10, CS11, CS12, CS13, CS14, CS3, CS7, CS8, CS15, CS16, CS17, CS18, CS19, CS20, CS21, CS23, CS24, CS27, CS28, CS29, CS31	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Children ,   Eligibility - Targeted Low-Income Pregnant Women ,   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 ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   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 ,   General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #37 (Revised) Medicaid Managed Care Rate Development Guide
[Medicaid] GenIC #37 (Revised): Medicaid Managed Care Rate Development Guide
[Medicaid] GenIC #43 (Revision): Certified Community Behavioral Health Clinic (CCBHC) Cost Report	CMS-10398 #43	CCBHC Cost Report
[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application	GenIC #45, GenIC #45	Demonstration Application ,   Compliance Checklist
[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations	4, 5b, 7a, 7b, 8b, 12g, 13d, 13e, 13f, 8a, 11a, 11b, 11c, 11d, 11e, 11f, 11g, 12a, 12b, 12c, 12d, 12e, 12f, 12h, 12i, 13a, 13b, 13c, 13g, 5a	Implementation Plan Template ,   Monitoring Report Template ,   Monitoring Report Workbook ,   Monitoring Protocol Template ,   Monitoring Protocol Workbook ,   Annual Availability Assessment ,   Initial Availability Assessment ,   Initial Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director ,   Initial Implementation Interview Email Invitation ,   Initial Implementation Interview Confirmation Email ,   Initial Implementation Interview Outlook Invitation ,   Initial Implementation Interview Reminder Email ,   Initial Implementation Interview Protocol with Instructions ,   Initial Implementation Interview Thank You Email ,   Provider Interview Introductory Email from CMS to State Medicaid Director ,   Provider Interview Introductory Email from RTI to State Medicaid Director ,   Provider Interview Introductory Email from State Medicaid Director ,   Provider Interview Email Invitation ,   Provider Interview Outlook Invitation ,   Provider Interview Confirmation Email ,   IMD Interview Protocol with Instructions ,   CMHC Interview Protocol with Instructions ,   Provider Interview Thank You Email ,   Follow-up Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director ,   Follow-up Implementation Interview Email Invitation ,   Follow-up Implementation Interview Confirmation Email ,   Follow-up Implementation Interview Outlook Invitation ,   Follow-up Implementation Interview Reminder Email ,   Follow-up Implementation Interview Protocol with Instructions ,   Follow-up Implementation Interview Thank You Email
[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis	3i, 3j, 4a, 4b, 4c, 4d, 4e, 4f, 4g, 1e, 1f, 1g, 1a, 1c, 1b, 3h, 1d, 3a, 3b, 3c, 3d, 3e, 3f, 3g	Characteristics/Implementation Introductory Email ,   Characteristics/Implementation Interview Email Invitation with Program Characteristics Grid ,   Interview Questions ,   Characteristics/Implementation Confirmation Email ,   Characteristics/Implementation Interview Invitation ,   Characteristics/Implementation Interview Reminder Email ,   Characteristics/Implementation Interview Thank You Email ,   MCO and Behavioral Health Stakeholder Interview Introductory Email ,   MCO and Behavioral Health Provider Stakeholder Interview Introductory Email ,   MCO and Behavioral Health Provider Stakeholder Interview Introductory Email ,   MCO and Behavioral Health Provider Stakeholder Interview Email Invitation ,   MCO and Behavioral Health Provider Stakeholder Interview Outlook Invitation ,   MCO and Behavioral Health Provider Stakeholder Interview Confirmation Email ,   MCO Protocol with Instructions ,   Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers) ,   Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers) ,   MCO and Behavioral Health Provider Stakeholder Interview Thank You Email ,   Follow-Up Implementation Interview Introductory Email ,   Follow-Up Implementation Interview Email Invitation ,   Follow-Up Implementation Interview Confirmation Email ,   Follow-Up Implementation Interview Outlook Invitation ,   Follow-Up Implementation Interview Reminder Email ,   Follow-Up Implementation Interview Protocol with Instructions ,   Follow-Up Implementation Interview Thank You Email
[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)	CMS-10398 #68	SPA Attachment 3.1: Section 1905(a)(29) Medication Assisted Treatment (MAT)
[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment	Attachment 1, Attachment 2, Attachment 3	Connecting Kids to Coverage Monthly Progress Report ,   Connecting Kids to Coverage Semi-Annual Progress Report ,   Connecting Kids to Coverage Final Report
[Medicaid] GenIC #83 (New) PACE SPA Preprint	#83	PACE SPA Preprint
[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide	Appendix B	PACE AWOP & Rate Package Submission Cover Sheet
[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative	GenIC #86, GenIC #86, GenIC #86	Reentry Demonstration Initiative Preprint ,   Reentry Implementation Plan Template ,   Reentry Budget Neutrality Formulation Workbook
[Medicaid] GenIC #88 (New): Medicaid/CHIP School-Based Services (SBS) Grants	CMS-10398 #88	SBS Grant Data Submission and TAC Participation Form
[Medicaid] GenIC #90 (New): CAA of 2024, Section 206 Planning Grant Reporting
[Medicaid] GenIC #91 (New): State Plan Amendment (SPA) Template for Medicaid Clinic Benefit	Supplement to Attachment 3.1	State Plan Amendment (SPA) Template for Medicaid Clinic Benefit
[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates	GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94	MES APD Template ,   MES OAPD Template ,   AoA Template ,   MES MDBT+CHIP Template ,   MES RFP Checklist ,   Operational Report Workbook ,   MES Project Status Report ,   Intake Form
[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools	CMS-10398 #96, CMS-10398 #96, CMS-10398 #96	Health Plan Reporting Template ,   State Fee-for-Service (FFS) Program Reporting Template ,   State Summary Template

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	19,623	0	0	0	0	19,623
Annual Time Burden (Hours)	450,000	0	0	0	0	450,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/27/2024

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