Information Collection

[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)

IC 276243 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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #68 SPA Attachment 3.1: Section 1905(a)(29) Medication Assisted Treatment (MAT) [Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)	Form
CMS-10398 #68 SPA Attachment 3.1: Section 1905(a)(29) Medication Assis GenIC 68 - SPA Template (508).pdf	Form
GenIC 68 - Generic Supporting Statement (2025 version 8).docx Generic Supporting Statement	IC Document
GenIC 68 - Template Crosswalk (508).pdf SPA Template Crosswalk	IC Document
Response to Public Comments (2025 version 2).docx Response to Public Comments	IC Document
m9w-4lrr-1529 - Comment.pdf Public Comment (palmbeachstate.edu)	IC Document
ma4-8j8x-ethp - Comment.pdf Public Comment (Anonymous)	IC Document
ma4-pfhc-44fc - Comment.pdf Public Comment (Anonymous 2)	IC Document

IC Title:

[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)

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 #68				Yes	Yes	Fillable Fileable

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		07/07/2025
SPA Template Crosswalk		07/07/2025
Response to Public Comments		07/07/2025
Public Comment (palmbeachstate.edu)		07/08/2025
Public Comment (Anonymous)		07/08/2025
Public Comment (Anonymous 2)		07/08/2025

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

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