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
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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
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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
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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