Information Collection

[Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template

IC 281883 under ICR 202610-0938-013 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form GenIC #99 Medicaid CCBHC Services SPA Coverage Template [Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template	Form and Instruction
GenIC #99 Medicaid CCBHC Services SPA Coverage Template CCBHC Services (1905(a)(31)) SPA Preprint (MSWord) 05-06-26 508c.docx	Form and Instruction
GenIC 99 - Generic Supporting Statement (2026 version 5).docx Generic Supporting Statement	IC Document
GenIC 99 - 0938-1148 Comment Response - CCBHC Services SPA Template 05-04-26 508c.pdf Response to Comments	IC Document
GenIC 99 - 0938-1148 Crosswalk of Changes 05-13-26 508c.pdf Crosswalk: Medicaid CCBHC Services SPA Coverage Template	IC Document
Comment - mom-brl7-yoch.pdf Comment: Missouri Behavioral Health Council	IC Document
Comment - mom-4kzq-srw5.docx Comment: Michigan Department of Health and Human Services	IC Document
Comment - mom-0y9i-ryzp.pdf Comment	IC Document
Comment - mom-0qwu-bjh2.pdf Comment: Missouri Department of Mental Health	IC Document
Comment - mok-wdn7-g4t6.pdf Comment: David Rocha	IC Document
Comment - mok-w99k-m34y.pdf Comment: David Rocha	IC Document
Comment - mok-w99k-m34y.pdf Comment: David Rocha	IC Document
Comment - mok-fp1f-ujas.pdf Comment: David Rocha	IC Document
Comment - mok-blka-qxce.pdf Comment: David Rocha	IC Document
Comment - moa-q8kf-ic6e.pdf Comment: Deborah Ogles	IC Document

IC Title:

Agency IC Tracking Number:

CMCS

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	GenIC #99				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
	Requested	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		08/11/2026
Response to Comments		08/11/2026
Crosswalk: Medicaid CCBHC Services SPA Coverage Template		08/11/2026
Comment: Missouri Behavioral Health Council		08/11/2026
Comment: Michigan Department of Health and Human Services		08/11/2026
Comment		08/11/2026
Comment: Missouri Department of Mental Health		08/11/2026
Comment: David Rocha		08/11/2026
Comment: David Rocha		08/11/2026
Comment: David Rocha		08/11/2026
Comment: David Rocha		08/11/2026
Comment: David Rocha		08/11/2026
Comment: Deborah Ogles		08/11/2026

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

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