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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
GenIC #3 - Alternative Benefit Plans (ABPs)
Unchanged
56
728
0
Form
CMS-10434 (#3)
GenIC #3 - Screen Shots (Alternative Benefit Plans)
GenIC # 45 (Transfer from 0938-1148): Maternal and Infant Health Quality
New
112
112
0
Form
CMS-10434 #45
MIHQM2017-AdminScreen
Form
CMS-10434 #45
MIHQM2017-CCW
GenIC #1 - Initial Application
Modified
56
476
0
Form
CMS-10434 (#1)
Initial Application
Form
CMS-10434 (#1)
Initial Application (SPA Administration)
Form
CMS-10434 (#1)
MACPro Homepage
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility
New
56
1120
0
Form and Instruction
CMS-10434 #15
Designation and Authority
Form and Instruction
CMS-10434 #15
Intergovernmental Cooperation Act Waivers
Form and Instruction
CMS-10434 #15
Eligibility Determinations and Fair Hearings
Form and Instruction
CMS-10434 #15
Organization and Administration
Form and Instruction
1
Single State Agency Assurances
Form and Instruction
1
Submission Summary
Form and Instruction
1
Medicaid State Plan
Form and Instruction
1
Public Comment
Form and Instruction
1
Tribal Input
Form and Instruction
1
Other Comment
Form and Instruction
1
MAGI Based Methodologies
Form and Instruction
1
MAGI Based Methodologies – Territories
Form and Instruction
1
Reasonable Classification of Children All
Form and Instruction
1
Reasonable Classification of Children Limit
Form and Instruction
1
Income Standard
Form and Instruction
1
AFDC Income Standards
Form and Instruction
1
Income Standards – Poverty Level – Territories
Form and Instruction
1
Income Standards - AFDC-related – Territories
Form and Instruction
1
Presumptive Eligibility for Children under Age 19
Form and Instruction
1
Qualified Entities
Form and Instruction
1
Financial Eligibility Requirements for Non-MAGI Groups
Form and Instruction
1
Presumptive Eligibility by Hospitals
Form and Instruction
1
Parents and Other Caretaker Relatives
Form and Instruction
1
Presumptive Eligibility for Parents and Other Caretaker Relatives
Form and Instruction
1
Pregnant Women
Form and Instruction
1
Presumptive Eligibility for Pregnant Women
Form and Instruction
1
Presumptive Eligibility for Pregnant Women
Form and Instruction
1
Financial Eligibility Requirements for Non-MAGI Groups – Territories
Form and Instruction
1
Optional Eligibility Groups
Form and Instruction
1
Infants and Children under Age 19
Form and Instruction
1
Infants and Children under Age 19 – Territories
Form and Instruction
1
Adult Group
Form and Instruction
1
Adult Group - Presumptive Eligibility
Form and Instruction
1
Adult Group - Presumptive Eligibility – Territories
Form and Instruction
1
Former Foster Care Children
Form and Instruction
1
Former Foster Care Children – Presumptive Eligibility
Form and Instruction
1
De-selected
Form and Instruction
1
Mandatory Eligibility Groups
Form and Instruction
1
Individuals above 133% FPL under Age 65
Form and Instruction
1
Individuals above 133% FPL under Age 65 - Presumptive Eligibility
Form and Instruction
1
Optional Coverage of Parents and Other Caretaker Relatives
Form and Instruction
1
Reasonable Classification of Individuals under Age 21
Form and Instruction
1
Children with Non IV-E Adoption Assistance
Form and Instruction
1
Optional Targeted Low Income Children
Form and Instruction
1
Individuals with Tuberculosis
Form and Instruction
1
Independent Foster Care Adolescents
Form and Instruction
1
Individuals Eligible for Family Planning Services
Form and Instruction
1
Individuals Eligible for Family Planning Services - Presumptive Eligibility
Form and Instruction
1
State Residency
Form and Instruction
1
Citizenship and Non-Citizenship
Form and Instruction
1
Eligibility Process
Form and Instruction
1
Application
GenIC #2 - CHIP State Plan Eligibility
Unchanged
56
1568
0
Form
CMS-10434 (#2)
CHIP Admin
Form
CMS-10434 (#2)
CHIP Eligibility
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
GenIC #22 - Health Home State Plan Amendment (SPA)
New
30
2400
0
Form
CMS-10434 #22
Health Homes Intro Screenshots
Form
CMS-10434 #22
Population and Enrollment Screenshots
Form
CMS-10434 #22
Geographic Limitations Screenshots
Form
CMS-10434 #22
Health Homes Services Screenshots
Form
CMS-10434 #22
Health Homes Providers Screenshots
Form
CMS-10434 #22
Health Homes Service Delivery Systems – Screenshots
Form
CMS-10434 #22
Health Homes Payment Methodologies – Screenshots
Form
CMS-10434 #22
Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots
Form
CMS-10434 #22
Health Homes Program Termination – Screenshots
Form
CMS-10398 #22
Submission Summary – Screenshots
Form
CMS-10434 #22
Medicaid State Plan – Screenshots
Form
CMS-10434 #22
Public Comment – Screenshots
Form
CMS-10434 #22
Tribal Input – Screenshots
Form
CMS-10434 #22
Other Comment – Screenshots
Other-SMDL Letter
Other-CMCS Informational Bulletin
Instruction
GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures
New
224
8960
0
Form
CMS-10434 #26
AQM2017-ABA
Form
CMS-10434 #26
AQM2017-AdminScreen
Form
CMS-10434 #26
AQM2017-AMM
Form
CMS-10434 #26
AQM2017-BCS
Form
CMS-10434 #26
AQM2017-CBP
Form
CMS-10434 #26
AQM2017-CCP
Form
CMS-10434 #26
AQM2017-CCS
Form
CMS-10434 #26
AQM2017-CDF
Form
CMS-10434 #26
AQM2017-CHL
Form
CMS-10434 #26
AQM2017-CPA
Form
CMS-10434 #26
AQM2017-FUA
Form
CMS-10434 #26
AQM2017-FUH
Form
CMS-10434 #26
AQM2017-FVA
Form
CMS-10434 #26
AQM2017-HA1C
Form
CMS-10434 #26
AQM2017-HPC
Form
CMS-10434 #26
AQM2017-HPCMI
Form
CMS-10434 #26
AQM2017-HVL
Form
CMS-10434 #26
AQM2017-IET
Form
CMS-10434 #26
AQM2017-MPM
Form
CMS-10434 #26
AQM2017-MSC
Form
CMS-10434 #26
AQM2017-OHD
Form
CMS-10434 #26
AQM2017-PCO1
Form
CMS-10434 #26
AQM2017-PC03
Form
CMS-10434 #26
AQM2017-PCR
Form
CMS-10434 #26
AQM2017-PPC
Form
CMS-10434 #26
AQM2017-PQI01
Form
CMS-10434 #26
AQM2017-PQI05
Form
CMS-10434 #26
AQM2017-PQI08
Form
CMS-10434 #26
AQM2017-PQI15
Form
CMS-10434 #26
AQM2017-SAA
Form
CMS-10434 #26
AQM2017-SSD
Form
CMS-10434 #26
AQM2018-ABA
Form
CMS-10434 #26
AQM2018-AdminScreen
Form
CMS-10434 #26
AQM2018-AMM
Form
CMS-10434 #26
AQM2018-AMR
Form
CMS-10434 #26
AQM2018-BCS
Form
CMS-10434 #26
AQM2018-CBP
Form
CMS-10434 #26
AQM2018-CCP
Form
CMS-10434 #26
AQM2018-CCS
Form
CMS-10434 #26
AQM2018-CCW
Form
CMS-10434 #26
AQM2018-CHL
Form
CMS-10434 #26
AQM2018-COB
Form
CMS-10434 #26
AQM2018-CPA
Form
CMS-10434 #26
AQM2018-FUA FUM
Form
CMS-10434 #26
AQM2018-FUH
Form
CMS-10434 #26
AQM2018-FVA
Form
CMS-10434 #26
AQM2018-HA1C
Form
CMS-10434 #26
AQM2018-HPC
Form
CMS-10434 #26
AQM2018-HPCMI
Form
CMS-10434 #26
AQM2018-HVL
Form
CMS-10434 #26
AQM2018-IET
Form
CMS-10434 #26
AQM2018-MPM AD
Form
CMS-10434 #26
AQM2018-MSC
Form
CMS-10434 #26
AQM2018-OHD
Form
CMS-10434 #26
AQM2018-PC01 AD
Form
CMS-10434 #26
AQM2018-PC03 AD
Form
CMS-10434 #26
AQM2018-PCR AD
Form
CMS-10434 #26
AQM2018-PPC AD
Form
CMS-10434 #26
AQM2018-PQI01
Form
CMS-10434 #26
AQM2018-PQI05
Form
CMS-10434 #26
AQM2018-PQI08
Form
CMS-10434 #26
AQM2018-PQI15
Form
CMS-10434 #26
AQM2018-SSA AD
Form
CMS-10434 #26
AQM2018-SSD AD
Form
CMS-10434 #26
CQM2017-ADD
Form
CMS-10434 #26
CQM2017-AdminScreen
Form
CMS-10434 #26
CQM2017-AMB
Form
CMS-10434 #26
CQM2017-APC
Form
CMS-10434 #26
CQM2017-APP
Form
CMS-10434 #26
CQM2017-AUD
Form
CMS-10434 #26
CQM2017-AWC
Form
CMS-10434 #26
CQM2017-BHRA
Form
CMS-10434 #26
CQM2017-CAP
Form
CMS-10434 #26
CQM2017-CHL
Form
CMS-10434 #26
CQM2017-CIS
Form
CMS-10434 #26
CQM2017-CLABSI
Form
CMS-10434 #26
CQM2017-CPC
Form
CMS-10434 #26
CQM2017-DEV
Form
CMS-10434 #26
CQM2017-FPC
Form
CMS-10434 #26
CQM2017-FUH
Form
CMS-10434 #26
CQM2017-IMA
Form
CMS-10434 #26
CQM2017-LBW
Form
CMS-10434 #26
CQM2017-MMA
Form
CMS-10434 #26
CQM2017-PC02
Form
CMS-10434 #26
CQM2017-PDENT
Form
CMS-10434 #26
CQM2017-PPC
Form
CMS-10434 #26
CQM2017-SEAL
Form
CMS-10434 #26
CQM2017-SRA
Form
CMS-10434 #26
CQM2017-StateSpecific
Form
CMS-10434 #26
CQM2017-W15
Form
CMS-10434 #26
CQM2017-W34
Form
CMS-10434 #26
CQM2017-WCC
Form
CMS-10434 #26
CQM2018-ADD-CH
Form
CMS-10434 #26
CQM2018-AdminScreen
Form
CMS-10434 #26
CQM2018-AMB-CH
Form
CMS-10434 #26
CQM2018-AMR-CH
Form
CMS-10434 #26
CQM2018-APC-CH
Form
CMS-10434 #26
CQM2018-APP-CH
Form
CMS-10434 #26
CQM2018-AUD-CH
Form
CMS-10434 #26
CQM2018-AWC-CH
Form
CMS-10434 #26
CQM2018-CAP-CH
Form
CMS-10434 #26
CQM2018-CCP-CH
Form
CMS-10434 #26
CQM2018-CCW-CH
Form
CMS-10434 #26
CQM2018-CDF-CH
Form
CMS-10434 #26
CQM2018-CHL-CH
Form
CMS-10434 #26
CQM2018-CIS-CH
Form
CMS-10434 #26
CQM2018-CLABSI-CH
Form
CMS-10434 #26
CQM2018-CPC-CH
Form
CMS-10434 #26
CQM2018-DEV-CH
Form
CMS-10434 #26
CQM2018-FUH-CH
Form
CMS-10434 #26
CQM2018-IMA-CH
Form
CMS-10434 #26
CQM2018-LBW-CH
Form
CMS-10434 #26
CQM2018-PC02-CH
Form
CMS-10434 #26
CQM2018-PDENT-CH
Form
CMS-10434 #26
CQM2018-PPC-CH
Form
CMS-10434 #26
CQM2018-SEAL-CH
Form
CMS-10434 #26
CQM2018-W15-CH
Form
CMS-10434 #26
CQM2018-W34-CH
Form
CMS-10434 #26
CQM2018-WCC-CH
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
GenIC #47 - Health Home Core Sets
New
30
1200
0
Form
HHQM1
Admin-Data-Source
Form
HHQM2
Admin-Hybrid-Data-Source
Form
HHQM3
Admin-Questions
Form
HHQM4
Admin-Screen
Form
HHQM5
Admin-Combined-Rates
Form
HHQM6
HHQM-ABA
Form
HHQM7
HHQM-AMB
Form
HHQM8
HHQM-CBP
Form
HHQM9
HHQM-CDF
Form
HHQM10
HHQM-CTR
Form
HHQM11
HHQM-FUH
Form
HHQM12
HHQM-IET
Form
HHQM13
HHQM-IU
Form
HHQM14
HHQM-NFU
Form
HHQM15
HHQM-PCR
Form
HHQM16
HHQM-PQI92
Form
HHQM17
HHQM-SSGM
Form
HHQM18
Hybrid-Data-Source
Form
HHQM19
Hybrid-or-EHR
Form
HHQM20
If-Data-Not-Reported
Form
HHQM21
Technical-Assistance
Total Burden Actually Used for Information Collections Under Currently Approved ICR:
620
16564
0
Total Burden Currently Requested for Information Collections Under Currently Approved ICR:
0
0
0
To view an IC, click on IC Title