GenICs Active as of 7-29-2026

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NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

07/29/2026

Department of Health and Human Services
Centers for Medicare & Medicaid Services
FOR CERTIFYING OFFICIAL:

David Hong

FOR CLEARANCE OFFICER:

Catherine Howard

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
07/14/2026
ACTION REQUESTED: Generic IC
[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment
IC TITLE:
ICR REFERENCE NUMBER:

202409-0938-028

AGENCY ICR TRACKING NUMBER:

CMCS

TITLE:

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions
(CMS-10398)
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

0938-1148

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 10/31/2027

BURDEN:

DISCONTINUE DATE:

RESPONSES

HOURS

COSTS

0

0

0

19,623

450,000

0

Change due to New Statute

0

0

0

Change due to Agency Discretion

0

0

0

Change due to Agency Adjustment

0

0

0

19,623

450,000

0

Previous
New
Difference

Change due to PRA Violation
TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Deputy Administrator,
Office Of Information And Regulatory Affairs

IC Title
Reinstatement of
Previously Approved
GenICs
GenIC #66 (Extension
from MACPro):
Eligibility Processing
Data Report and
Renewal Compliance
Template

Form No.

List of ICs
Form Name

Misc (see spreadsheet) Misc (see spreadsheet)

GenIC #66, GenIC #66, Compliance Assessment
GenIC #66
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 GenIC #82
Quality Improvement
from MACPro): Quality
Affinity Group Expression
Improvement Affinity
of Interest Form
Group Expression of
Interest Form
GenIC #85 (New): 3.1- Attachment 3.1-M
Attestation for Mandatory
M State Plan
pages 1 and 2,
Coverage of Eligible
Amendment (SPA)
Supplement to
Juveniles, Targeted Case
Templates for Eligible Attachment 3.1,
Management (TCM) for
Juveniles Who are
Attachment 3.1-M page Mandatory Coverage of
Inmates of a Public
3
Eligible Juveniles,
Institution
Attestation for Optional
Coverage of Eligible
Juveniles
[Medicaid] GenIC #88 CMS-10398 #88
SBS Grant Data
(New): Medicaid/CHIP
Submission and TAC
School-Based Services
Participation Form
(SBS) Grants
[Medicaid] GenIC #86 GenIC #86, GenIC #86, Reentry Demonstration
(New) Section 1115
GenIC #86
Initiative Preprint, Reentry
Reentry Demonstration
Budget Neutrality
Initiative
Formulation Workbook,
Reentry Implementation
Plan Template
[Medicaid] GenIC #83 #83
PACE SPA Preprint
(New) PACE SPA
Preprint
[Medicaid] GenIC #84 Appendix B
PACE AWOP & Rate
(New): PACE Medicaid
Package Submission
Capitation Rate Setting
Cover Sheet
Guide
[Medicaid] GenIC #90
(New): CAA of 2024,
Section 206 Planning
Grant Reporting
[Medicaid] GenIC #91 Supplement to
State Plan Amendment
(New): State Plan
Attachment 3.1
(SPA) Template for
Amendment (SPA)
Medicaid Clinic Benefit
Template for Medicaid
Clinic Benefit
[Medicaid] GenIC #37
(Revised): Medicaid
Managed Care Rate
Development Guide
GenIC #87 (New):
CMS-10398 #87
Managed Care Plan
Managed Care Plan
(MCP) Medical Loss Ratio
(MCP) Medical Loss
(MLR) Reporting
Ratio (MLR) Reporting
Template
Template

CFR Citation

Hrs/$/Resp
80,232 / 0 / 6,541
21,056 / 0 / 1,400

60 / 0 / 20

4,872 / 0 / 168

1,278 / 0 / 114

300 / 0 / 30

5,560 / 0 / 40
17 / 0 / 34

1,200 / 0 / 300

1,400 / 0 / 56

1/0/2

2,350 / 0 / 470

IC Title

Form No.

GenIC #93 (New):
CMS-10398 #93
Medicaid 1915(l) State
Plan Option to Provide
Medical Assistance for
Eligible Individuals Who
Are Patients in Eligible
Institutions for Mental
Diseases
[Medicaid] GenIC #17 CS15, CS11, CS3,
(Revised): CHIP State CS7, CS8, CS9, CS10,
Plan Eligibility
CS12, CS13, CS14,
CS16, CS17, CS18,
CS19, CS20, CS21,
CS23, CS24, CS27,
CS28, CS29, CS31

[Medicaid] GenIC #68 CMS-10398 #68
(Revised): SPA
Template for
1905(a)(29) of the SSA
Medication Assisted
Treatment (MAT)

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

Attachment 3.1-LSUD/IMD (SPA
Templates)

1,400 / 0 / 56

MAGI-Based Income
Methodologies, Eligibility Pregnant Women Who
Have Access to Public
Employee Coverage,
Eligibility for Medicaid
Expansion Program,
Eligibility - Targeted LowIncome Children, Eligibility
- Targeted Low-Income
Pregnant Women,
Eligibility - Coverage From
Conception to Birth,
Eligibility - Children 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 , Other
Eligibility Criteria –
Spenddowns, NonFinancial 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
SPA Attachment 3.1:
Section 1905(a)(29)
Medication Assisted
Treatment (MAT)

5 / 0 / 56

1,400 / 0 / 56

IC Title
[Medicaid] GenIC #94
(New): Streamlining
Medicaid Enterprise
Systems (MES)
Advance Planning
Documents (APD)
Templates

Form No.

List of ICs
Form Name

GenIC #94, GenIC #94, MES APD Template, MES
GenIC #94, GenIC #94, OAPD Template, AoA
GenIC #94, GenIC #94, Template, Intake Form ,
GenIC #94, GenIC #94 MES RFP Checklist,
Operational Report
Workbook, MES Project
Status Report, MES
MDBT+CHIP Template
[Medicaid] GenIC #56 GenIC #56, GenIC #56 PMDA Budget Neutrality
(Revised): Section 1115
Monitoring Workbook,
Demonstration: Budget
State User Budget
Neutrality Monitoring
Neutrality Playbook
Workbook

CFR Citation

Hrs/$/Resp
86,096 / 0 / 3,314

1,106 / 0 / 159

IC Title
[Medicaid] GenIC #64
(Revision) Medicaid
Section 1115
Substance Use
Disorder (SUD)
Demonstrations:
Federal Meta Analysis

Form No.

List of ICs
Form Name

1d, 3a, 3b, 3c, 3d, 3e, Characteristics/Implement
3f, 3g, 3h, 3i, 3j, 4a, 4b, ation Confirmation Email,
4c, 4d, 4e, 4f, 4g, 1e, 1f, MCO and Behavioral
1g, 1a, 1c, 1b
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 (NonResidential Providers),
MCO and Behavioral
Health Provider
Stakeholder Interview
Thank You Email, FollowUp Implementation
Interview Introductory
Email, Follow-Up
Implementation Interview
Email Invitation, FollowUp Implementation
Interview Confirmation
Email, Follow-Up
Implementation Interview
Outlook Invitation, FollowUp Implementation
Interview Reminder Email,
Follow-Up Implementation
Interview Protocol with
Instructions, Follow-Up
Implementation Interview
Thank You Email,
Characteristics/Implement
ation Interview Invitation,
Characteristics/Implement
ation Interview Reminder
Email,
Characteristics/Implement
ation Interview Thank You
Email,
Characteristics/Implement
ation Introductory Email,

CFR Citation

Hrs/$/Resp
506 / 0 / 384

IC Title

[Medicaid] GenIC #17
(revision): CHIP State
Plan Eligibility

Form No.

List of ICs
Form Name

Interview Questions ,
Characteristics/Implement
ation Interview Email
Invitation with Program
Characteristics Grid
CS15, CS13, CS16,
MAGI-Based Income
CS14, CS12, CS17,
Methodologies, Eligibility CS18, CS19, CS20,
Deemed Newborns, Other
CS21, CS23, CS24,
Eligibility Criteria –
CS27, CS28, CS29,
Spenddowns, Eligibility CS31, CS3, CS7, CS8, Children Ineligible for
CS9, CS10, CS11
Medicaid as a Result of
the Elimination of Income
Disregards, Eligibility Dental Only Supplemental
Coverage, 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, NonFinancial 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, 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

[Medicaid] GenIC #37
(Revised) Medicaid
Managed Care Rate
Development Guide
[Medicaid] GenIC #43 CMS-10398 #43
(Revision): Certified
Community Behavioral
Health Clinic (CCBHC)
Cost Report

CFR Citation

Hrs/$/Resp

5 / 0 / 56

205 / 0 / 137

CCBHC Cost Report

14,419 / 0 / 440

IC Title

Form No.

List of ICs
Form Name

[Medicaid] GenIC #45 GenIC #45, GenIC #45 Demonstration
(Revised): Certified
Application, Compliance
Community Behavioral
Checklist
Health Clinic (CCBHC)
2024 State Proposal
Demonstration
Application

CFR Citation

Hrs/$/Resp
194 / 0 / 43

IC Title

Form No.

List of ICs
Form Name

[Medicaid] GenIC #59 12g, 13d, 13e, 13f, 8a, IMD Interview Protocol
(Revised): Medicaid
11a, 11b, 11c, 11d, 11e, with Instructions, FollowSection 1115 Severe
11f, 11g, 12a, 12b, 12c, up Implementation
Mental Illness (SMI) and 12d, 12e, 12f, 12h, 12i, Interview Outlook
Children with Serious
13a, 13b, 13c, 13g, 5a, Invitation, Follow-up
Emotional Disturbance 4, 5b, 7a, 7b, 8b
Implementation Interview
(SED) Demonstrations
Reminder Email, Followup Implementation
Interview Protocol with
Instructions, 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, 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 Thank You
Email, Monitoring Report
Template, Implementation
Plan Template, Monitoring
Report Workbook,

CFR Citation

Hrs/$/Resp
5 / 0 / 329

IC Title

[Medicaid] GenIC #96
(New): Mental Health
(MH) and Substance
Use Disorder (SUD)
Parity Reporting Tools
[Medicaid] GenIC #17
(Revised) CHIP State
Plan Eligibility

Form No.

List of ICs
Form Name

Monitoring Protocol
Template, Monitoring
Protocol Workbook,
Annual Availability
Assessment
CMS-10398 #96, CMS- Health Plan Reporting
10398 #96, CMS-10398 Template, State Summary
#96
Template, State Fee-forService (FFS) Program
Reporting Template
CS12, CS13, CS14,
Eligibility for Dental Only
CS15, CS16, CS17,
Supplemental Coverage,
CS18, CS19 , CS20,
Eligibility - Deemed
CS21, CS23, CS24,
Newborns, Eligibility CS27, CS28, CS29,
Children Ineligible for
CS31, CS11, CS10,
Medicaid as a Result of
CS9, CS8, CS3, CS7
the Elimination of Income
Disregards, MAGI-Based
Income Methodologies,
Other Eligibility Criteria –
Spenddowns, NonFinancial 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, Eligibility for
Pregnant Women Who
Have Access to Public
Employee Coverage,
Eligibility for Children Who
Have Access to Public
Employee Coverage,
Eligibility for Coverage
From Conception to Birth,
Eligibility for Targeted
Low-Income Pregnant
Women, Eligibility for
Medicaid Expansion
Program, Eligibility for
Targeted Low-Income
Children

CFR Citation

Hrs/$/Resp

6,074 / 0 / 93

5 / 0 / 56

IC Title

Form No.

[Medicaid] GenIC
Attachment 1,
#7(Revised):
Attachment 2,
Connecting Kids to
Attachment 3
Coverage Outreach and
Enrollment

List of ICs
Form Name

CFR Citation

Connecting Kids to
Coverage Monthly
Progress Report ,
Connecting Kids to
Coverage Semi-Annual
Progress Report,
Connecting Kids to
Coverage Final Report
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
2,150 / 0 / 375

231,896