Information Collection

[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook

IC 277663 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⚠️ Notice: This information collection may be referencing outdated material.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 GenIC #56 PMDA Budget Neutrality Monitoring Workbook [Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	Form and Instruction
Form GenIC #56 State User Budget Neutrality Playbook [Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook	Form and Instruction
BN-Monitoring-Workbook-Training-Video-Transcript.docx	Instruction
GenIC #56 PMDA Budget Neutrality Monitoring Workbook MASTER BN Workbook Template - v2.14 20250710_CLEAN_508.xlsm	Form and Instruction
GenIC #56 State User Budget Neutrality Playbook #56-Playbook-SU-Budget Neutrality-1115PMDA-20250711.docx	Form and Instruction
GenIC 56 - Generic Supporting Statement (2025 version 18).docx Generic Supporting Statement	IC Document
Comment - mfb-icog-7fyg.pdf Public Comment (Out of Scope)	IC Document
BN-Monitoring-Workbook-Crosswalk-of-Changes.xlsx Crosswalk :Workbook	IC Document
MASTER BN Workbook Template - v2.14 20250710_REDLINE.xlsm Redline: Workbook	IC Document
BN Monitoring Playbook Crosswalk of Changes.xlsx Crosswalk: Playbook	IC Document
#56 Playbook-SU-Budget Neutrality-1115PMDA-20250711_REDLINE.docx Redline: Playbook	IC Document
BN-Monitoring-Workbook-training-video-transcript-crosswalk-of-changes.xlsx Crosswalk: Video Transcript	IC Document
BN Video Transcript - 20250710_REDLINE.docx Redline: Video Transcript	IC Document

IC Title:

[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	GenIC #56	Yes	Yes	Fillable Fileable
Form and Instruction	GenIC #56	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

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	159	159
Annual IC Time Burden (Hours)	1,106	1,106
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		09/23/2025
Public Comment (Out of Scope)		09/23/2025
Crosswalk :Workbook		09/23/2025
Redline: Workbook		09/23/2025
Crosswalk: Playbook		09/23/2025
Redline: Playbook		09/23/2025
Crosswalk: Video Transcript		09/23/2025
Redline: Video Transcript		09/23/2025

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

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