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Agenda
Reg Review
ICR
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
To view an IC, click on IC Title