Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions New 112 2240 0 Form CMS-10398-004 Recovery Audit Contractor (RAC) Programs at a Glance (Phase III)
Form CMS-10398-005 State Medicaid Payment Suspensions
BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26) New 56 6205 0 Form and Instruction CMS-10398 Performance Indicator Specification Template
Form and Instruction CMS-10398 34 Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children’s Health Insurance Program
Form and Instruction CMS-10398 Medicaid Adult Quality Measures Template
Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21) New 52 2240 0 Form CMS-10398 (#20) PERM Pilot Submission Template
Instruction
Form CMS-10398 (#21) Threshold Methodology for Identification of Applicable FMAP Rates
Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26) New 56 2352 0 Form CMS-10398 (#25) Tobacco Cessation Quitline Expenditures - Participation in Medicaid Administration Federal Financial Participation (FFP)
Form and Instruction CMS-10398 (#26) Medicaid Adult Core Set Measures Reporting Template in CARTS
Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24) New 160 6720 0 Form CMS-10398 (#22) Health Home State Plan Amendment
Form CMS-10398 (#22) Health Homes Administrative Component
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-10398 (#23) ACR Supplemental Payment Demonstration Guidance
Instruction
Instruction
Form CMS-10398 (#23) Funding Questions
Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments New 107 4688 0 Form and Instruction CMS-10398 #11 MAGI-based Eligibility Verification Plan
Form CMS-10398 #12 Reimbursement Template - Physician Services (Attachment 4.19-B)
Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction New 169 3380 0 Form and Instruction CMS-10398-007 CHIPRA Cycle II - Outreach and Enrollment Grant Semi-Annual Report Template
Form and Instruction CMS-10398-006 Medicaid Buy-In Program: 2010 Policy Update
Instruction
Instruction
Form and Instruction CMS-10398-008 Payer Initiated Eligibility/Benefit (PIE) Transaction - DRA Companion Guide
Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application New 112 4480 0 Instruction
Form and Instruction CMS-10398-009 Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
Form CMS-10398-10 List of Frequently Requested Waivers and Expenditure Authorities
Other-1115 Demo - Information on Cost Sharing Requirements
Form CMS-10398-10 Benefit Specifications and Provider Qualifications
Form CMS-10398-10 Long Term Services Benefit Specifications and Provider Qualifications
Form and Instruction CMS-10398-10 Budget Neutrality Form
Form and Instruction CMS-10398-10 Demonstration Financing Form
Other-1115 Demo - List of Medicaid Eligibility Groups
Other-1115 Demo - List of Medicaid and CHIP Benefits
Form CMS-10398-10 1115 Demonstration Application Budget Neutrality Table Shell
Form CMS-10398-10 Long Term Services and Supports Form
Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37) New 50 0 0 Form and Instruction CMS-10398 (#20) User Guide - PERM Round 1 Findings Submission
Form and Instruction CMS-10398 (#20) User Guide - PERM Round 2 Proposal Submission
Form CMS-10398 (#36) DOMA Same Sex CHIP Template
Form CMS-10398 (#36) DOMA Same Sex Medicaid Template
Instruction
Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38) New 1663 11487 0 Form CMS-10398 (#19) Eligibility and Enrollment Performance Indicator Monthly Report
Form CMS-10398 (#38) Section 1115 Demonstration Application Template
CHIP Annual Report Template System (CARTs) New 168 5600 0 Form CMS-10398-001 CHIP Annual Report Template System (CARTs)
Form and Instruction CMS-10398-002 2011 National Summary Data Dictionary
Form and Instruction CMS-10398-002 2011 Medicaid Managed Care Enrollment Data Dictionary
Form CMS-10398-003 Medicaid Recovery Audit Contractor (RAC) Program
CHIP State Plan Eligibility (ICR #17) New 56 2800 0 Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7) New 4 80 0 Form and Instruction CMS-10398 (#7) Connecting Kids to Coverage Grant Semi-Annual Report Template for Grantees
Collection # 16: Federally-Facilitated Marketplace Integration Data Collection Tool New 56 1120 0 Form CMS-10398 Federally Facilitated Marketplace and State Based Rules Integration Plan (CHIP)
Collection #15 Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10398 A1-A3
Form CMS-10398 S10
Form CMS-10398 S14
Form CMS-10398 S21
Form CMS-10398 S25
Form CMS-10398 S28
Form CMS-10398 S30
Form CMS-10398 S32
Form CMS-10398 S33
Form CMS-10398 S50
Form CMS-10398 S51
Form CMS-10398 S52
Form CMS-10398 S53
Form CMS-10398 S54
Form CMS-10398 S55
Form CMS-10398 S57
Form CMS-10398 S59
Form CMS-10398 S88
Form CMS-10398 S89
Form CMS-10398 S94
Eligibility and Enrollment Performance Indicators (Collection #19 ) New 56 2240 0 Other-Template
Information Collection #18: Alternative Benefit Plans New 56 448 0 Form CMS-10398 (#18) Mock-up of Interim Form for Alternative Benefit Plans
MAGI Conversion Plan (Information Collection #14 ) New 56 1120 0 Form and Instruction CMS-10398 (#14) 14 MAGI Conversion Plan
MAGI Conversion Plan Part 2 (GenIC #27) New 56 1120 0 Form and Instruction CMS-10398 (#27) Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
MMIS APD Template NCCI Coding Initiative (Information Collection #28) New 280 840 0 Form CMS-10398 (#28) Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State's Medicaid Management Information System (MMIS)
Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Instruction
Instruction
Form CMS-10398 (13) Nursing Facility UPL Guidance
Form CMS-10398 (13) Outpatient Hospital UPL Guidance
Form CMS-10398 (13) Inpatient Hospital UPL Guidance
Instruction
Medicaid Premiums and Cost Sharing (#29) New 10 50 0 Form CMS-10398 (#29) Medicaid Premiums and Cost Sharing
Instruction
Instruction
Instruction
Instruction
Instruction
Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33) New 42 3278 0 Form CMS-10398 (#32) Preprint - Provider-Preventable Conditions for Non-Payment under Section 4.19
Instruction
Form CMS-10398 (#33) DRA 6062 (Preprint Attachments 2.2-A and 2.6-A)
Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415 New 1 0 0 Other-
Statewide HCBS Transition Plans (# 31) New 48 2016 0 Form CMS-10398 (#31) Sample Template for State Settings’ Analysis
Instruction
Instruction
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 3538 67864 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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