Information Collection

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

IC 276021 under ICR 202409-0938-028 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

2026-07-30 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #93 Attachment 3.1-L-SUD/IMD (SPA Templates) 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
CMS-10398 #93 Attachment 3.1-L-SUD/IMD (SPA Templates) Gen IC 93 - 1915(l) SPA Template - CAA 2024 05-06-25.docx - 508.pdf	Form
GenIC 93 - Generic Supporting Statement (2025 version 14).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #93				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: 56

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	56	56
Annual IC Time Burden (Hours)	1,400	1,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		06/30/2025

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

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