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[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations

IC 279189 under ICR 202409-0938-028 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 4
Implementation Plan Template [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 5a
Monitoring Report Template [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 5b
Monitoring Report Workbook [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 7a
Monitoring Protocol Template [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 7b
Monitoring Protocol Workbook [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 8b
Annual Availability Assessment [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 8a
Initial Availability Assessment [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11a
Initial Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11b
Initial Implementation Interview Email Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11c
Initial Implementation Interview Confirmation Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11d
Initial Implementation Interview Outlook Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11e
Initial Implementation Interview Reminder Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 11f
Initial Implementation Interview Protocol with Instructions [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form and Instruction
Form 11g
Initial Implementation Interview Thank You Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12a
Provider Interview Introductory Email from CMS to State Medicaid Director [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12b
Provider Interview Introductory Email from RTI to State Medicaid Director [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12c
Provider Interview Introductory Email from State Medicaid Director [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12d
Provider Interview Email Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12e
Provider Interview Outlook Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12f
Provider Interview Confirmation Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 12g
IMD Interview Protocol with Instructions [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form and Instruction
Form 12h
CMHC Interview Protocol with Instructions [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form and Instruction
Form 12i
Provider Interview Thank You Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13a
Follow-up Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13b
Follow-up Implementation Interview Email Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13c
Follow-up Implementation Interview Confirmation Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13d
Follow-up Implementation Interview Outlook Invitation [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13e
Follow-up Implementation Interview Reminder Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Form 13f
Follow-up Implementation Interview Protocol with Instructions [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form and Instruction
Form 13g
Follow-up Implementation Interview Thank You Email [Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations		 Form
Attachment 1. Video - Overview of the Standardized Monitoring Report Process.docx
cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ 		Other-Video: Overview of the Standar
Attachment 2. Video - Populating and Submitting Monitoring Templates.docx
cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ 		Other-Video: Populating and Submitti
Attachment 3. Video - Downloading 1115 Monitoring Report Templates.docx
cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ 		Other-Video: Downloading 1115 Monito
Attachment 5c - Monitoring Report Instructions.pdf Instruction
Attachment 6 - Monitoring Metrics Technical Specifications.pdf Instruction
Attachment 7c - Monitoring Protocol Instructions.pdf Instruction
Attachment 9 - HIT Plan Instructions.pdf Instruction
Attachment 10 - State Medicaid Directors letter (SMDL) #18-011.pdf Other-State Medicaid Directors lette
4 Implementation Plan Template
Attachment 4. Implementation Plan Template.docx 		Form
5a Monitoring Report Template
Attachment 5a. Monitoring Report Template_Clean 508.docx 		Form
5b Monitoring Report Workbook
Attachment 5b. Monitoring Workbooks_Clean.xlsx 		Form
7a Monitoring Protocol Template
Attachment 7a. Monitoring Protocol Template_Clean 508.docx 		Form
7b Monitoring Protocol Workbook
Attachment 7b - Monitoring Protocol Workbook.xlsx 		Form
8b Annual Availability Assessment
Attachment 8b. Annual Availability Assessment.xlsx 		Form
8a Initial Availability Assessment
Attachment 8a. Initial Availability Assessment_Clean.xlsm 		Form
11a Initial Implementation Interview Introductory Email from
Attachment 11a. Initial SMI Demonstration Implementation Intro Email from CMS to State Medicaid Directors.docx 		Form
11b Initial Implementation Interview Email Invitation
Attachment 11b. Initial SMI Demonstration Implementation Intro Email RTI to State.docx 		Form
11c Initial Implementation Interview Confirmation Email
Attachment 11c. Initial SMI Demonstration Implementation Interview Confirmation Email.docx 		Form
11d Initial Implementation Interview Outlook Invitation
Attachment 11d. Initial SMI Demonstration Implementation Interview Outlook Invitation.docx 		Form
11e Initial Implementation Interview Reminder Email
Attachment 11e. Initial SMI Demonstration Implementation Interview Reminder Email.docx 		Form
11f Initial Implementation Interview Protocol with Instructi
Attachment 11f. Initial SMI Demonstration Implementation Interview Protocol.docx 		Form and Instruction
11g Initial Implementation Interview Thank You Email
Attachment 11g. Initial SMI Demonstration Implementation Interview Thank You E-mail.docx 		Form
12a Provider Interview Introductory Email from CMS to State
Attachment 12a. Provider Interview Introductory Email to SMD from CMS.docx 		Form
12b Provider Interview Introductory Email from RTI to State
Attachment 12b. Provider Interview Introductory Email from RTI to SMD.docx 		Form
12c Provider Interview Introductory Email from State Medicai
Attachment 12c. Provider Introductory Email from SMD.docx 		Form
12d Provider Interview Email Invitation
Attachment 12d. Provider Interview Introductory Email.docx 		Form
12e Provider Interview Outlook Invitation
Attachment 12e. Provider Interview Outlook Invitation.docx 		Form
12f Provider Interview Confirmation Email
Attachment 12f. Provider Interview Confirmation Email.docx 		Form
12g IMD Interview Protocol with Instructions
Attachment 12g. IMD Interview Protocol.docx 		Form and Instruction
12h CMHC Interview Protocol with Instructions
Attachment 12h. CMHC Interview Protocol.docx 		Form and Instruction
12i Provider Interview Thank You Email
Attachment 12i. Provider Interview Thank You Note.docx 		Form
13a Follow-up Implementation Interview Introductory Email fr
Attachment 13a. Follow-up SMI Demonstration Implementation Interview Intro Email from CMS to SMD.docx 		Form
13b Follow-up Implementation Interview Email Invitation
Attachment 13b. Follow-up SMI Demonstration Implementation Interview Email Invitation.docx 		Form
13c Follow-up Implementation Interview Confirmation Email
Attachment 13c. Follow-up SMI Demonstration Implementation Interview Confirmation Email.docx 		Form
13d Follow-up Implementation Interview Outlook Invitation
Attachment 13d. Follow-up SMI Demonstration Implementation Interview Outlook Invitation Text.docx 		Form
13e Follow-up Implementation Interview Reminder Email
Attachment 13e. Follow-up SMI Demonstration Implementation Interview Reminder Email.docx 		Form
13f Follow-up Implementation Interview Protocol with Instruc
Attachment 13f. Follow-up SMI Demonstration Implementation Interview Protocol.docx 		Form and Instruction
13g Follow-up Implementation Interview Thank You Email
Attachment 13g. Follow-up SMI Demonstration Implementation Interview Thank You Email.docx 		Form
GenIC 59 - Generic Supporting Statement (2026 version 12).docx
Generic Supporting Statement		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Other-Video: Overview of the Standardized Monitoring Report Process https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ No   Printable Only
Other-Video: Populating and Submitting Monitoring Templates https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ No   Printable Only
Other-Video: Downloading 1115 Monitoring Report Templates https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ No   Printable Only
Form 4 Yes Yes Fillable Fileable
Form 5a Yes Yes Fillable Fileable
Instruction Yes Yes Printable Only
Instruction No   Printable Only
Form 5b Yes Yes Fillable Fileable
Form 7a Yes Yes Fillable Fileable
Form 7b Yes Yes Fillable Fileable
Instruction Yes Yes Printable Only
Form 8b Yes Yes Fillable Fileable
Instruction Yes Yes Fillable Fileable
Other-State Medicaid Directors letter (SMDL) #18-011 No   Printable Only
Form 8a Yes Yes Fillable Fileable
Form 11a Yes Yes Fillable Fileable
Form 11b Yes Yes Fillable Fileable
Form 11c Yes Yes Fillable Fileable
Form 11d Yes Yes Fillable Fileable
Form 11e Yes Yes Fillable Fileable
Form and Instruction 11f Yes Yes Fillable Fileable
Form 11g Yes Yes Fillable Fileable
Form 12a Yes Yes Fillable Fileable
Form 12b Yes Yes Fillable Fileable
Form 12c Yes Yes Fillable Fileable
Form 12d Yes Yes Fillable Fileable
Form 12e Yes Yes Fillable Fileable
Form 12f Yes Yes Fillable Fileable
Form and Instruction 12g Yes Yes Fillable Fileable
Form and Instruction 12h Yes Yes Fillable Fileable
Form 12i Yes Yes Fillable Fileable
Form 13a Yes Yes Fillable Fileable
Form 13b Yes Yes Fillable Fileable
Form 13c Yes Yes Fillable Fileable
Form 13d Yes Yes Fillable Fileable
Form 13e Yes Yes Fillable Fileable
Form and Instruction 13f Yes Yes Fillable Fileable
Form 13g Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 329 0 329 0 0 0
Annual IC Time Burden (Hours) 5 0 5 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Generic Supporting Statement 03/13/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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