Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum New 51 38 0 Form and Instruction CMS-10398.GenIC#11 CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-30-20)
Form and Instruction CMS-10398.GenIC#11. CMS-10398.GenIC#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-30-20)
GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs New 54 5 0 Instruction
Form and Instruction CMS-10398 #24 II. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
Form and Instruction CMS-10398 #24 V. Clinic Upper Payment Limit (UPL) Guidance
Instruction
Form and Instruction CMS-10398 #24 VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance
Instruction
Form and Instruction CMS-10398 #24 IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction
Instruction
Form CMS-10398 #24 XI. Medicaid Qualified Practitioner Services (Physician) Standard Template
Form CMS-10398 #24 XII. Institutes for Mental Diseases (IMD) Standard Template
Form CMS-10398 #24 XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template
Form CMS-10398 #24 XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template
Form CMS-10398 #24 XV. Clinic Standard Template
Instruction
Form and Instruction CMS-10398 #24 IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration
GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates New 140 3080 0 Form and Instruction CMS-10398 #58 Implementation Plan Template
Form and Instruction CMS-10398 #58 Monitoring Protocol - Planned Metrics
Instruction
Form and Instruction CMS-10398 #58 Monitoring Report
Instruction
Instruction
Other-SMDL
GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations New 110 3140 0 Instruction
Instruction
Instruction
Form CMS-10398 #59 Implementation Plan Template
Form CMS-10398 $59 Monitoring Report Template
Instruction
Form CMS-10398 #59 Monitoring Protocol Template
Instruction
Instruction
Form and Instruction CMS-10398 #59 Monitoring Workbook
Form and Instruction CMS-10398 #59 Current Availability Assessment
Instruction
Instruction
GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs) New 56 2240 0 Form and Instruction CMS-10398 #1 Framework for the Annual Report of the Children’s Health Insurance Plans Under Title XXI of the Social Security Act
GenIC #1 (Revised): CHIP Annual Report Template System (CARTS) New 51 5 0 Form # 1 CARTS
GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS) New 56 5 0 Form and Instruction CMS-10398 #1 CHIP Annual Report Template System (CARTS)
GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application New 5 1600 0 Form CMS-10398 #10 Benefit Specifications and Provider Qualifications
Form and Instruction CMS-10398 #10 Budget Neutrality Form
Form and Instruction CMS-10398 #10 Demonstration Financing Form
Instruction
Form CMS-10398 #10 BN Table Shell
Other-List of eligibility Groups
Form CMS-10398 #10 Long Term Services and Supports Form
Other-List of Medicaid and CHIP Benefits
Other-List of Frequently Requested Waivers and Expenditure Authorities
Form CMS-10398 #10 Long Term Services Benefit Specifications and Provider Qualifications
Form and Instruction CMS-10398 #10 Section 1115 Demonstration Program Application Guide
GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan New 56 2240 0 Form and Instruction CMS-10398 #11 Verification Plan Template
GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Instruction
Form and Instruction CMS-10398 #13 Nursing Facility UPL Guidance
Instruction
Form and Instruction CMS-10398 #13 Outpatient Hospital UPL Guidance
Form and Instruction CMS-10398 #13 Inpatient Hospital UPL Guidance
Form CMS-10398 #13 NF Template
Form CMS-10398 #13 OP Template
Form CMS-10398 #13 IP Template
Form CMS-10398 #13 Inpatient Hospital UPL Guidance
Form CMS-10398 #13 Outpatient Hospital UPL Guidance
GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 54 5 0 Instruction
Form and Instruction CMS-10398 #13 Attachment B – Nursing Facility UPL Guidance
Instruction
Form and Instruction CMS-10398 #13 Attachment D – Outpatient Hospital UPL Guidance
Instruction
Form and Instruction CMS-10398 #13 Attachment F – Inpatient Hospital UPL Guidance
Form CMS-10398 #13 Attachment G – Nursing Facility Standard Template
Form CMS-10398 #13 Attachment H – Outpatient Hospital Standard Template
Form CMS-10398 #13 Attachment I – Inpatient Hospital Standard Template
GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility New 56 1120 0 Form and Instruction CMS-10398 #15 Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority
Form and Instruction CMS-10398 #15 Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies
Form and Instruction CMS-10398 #15 Tab S14 – Medicaid Eligibility: AFDC Income Standards
Form and Instruction CMS-10398 #15 Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals
Form and Instruction CMS-10398 #15 Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
Form and Instruction CMS-10398 #15 Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women
Form and Instruction CMS-10398 #15 Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
Form and Instruction CMS-10398 #15 Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group
Form and Instruction CMS-10398 #15 Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
Form and Instruction CMS-10398 #15 Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
Form and Instruction CMS-10398 #15 Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
Form and Instruction CMS-10398 #15 Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
Form and Instruction CMS-10398 #15 Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
Form and Instruction CMS-10398 #15 Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
Form and Instruction CMS-10398 #15 Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
Form and Instruction CMS-10398 #15 Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
Form and Instruction CMS-10398 #15 Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
Form and Instruction CMS-10398 #15 Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency
Form and Instruction CMS-10398 #15 Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
Form and Instruction CMS-10398 #15 Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process
GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool New 56 1120 0 Form CMS-10398 #16 Federally Facilitated Marketplace and State Based Rules Integration Charts
Form CMS-10398 #16 Federally Facilitated Marketplace and State Based Rules Integration Charts
GenIC #17 (Extension w/o change): CHIP State Plan Eligibility New 56 2800 0 Form CMS-10398 #17 CS3 - Eligibility for Medicaid Expansion Program
Form CMS-10398 #17 CS8 - Eligibility - Targeted Low-Income Pregnant Women
Form CMS-10398 #17 CS9 - Eligibility - Coverage From Conception to Birth
Form CMS-10398 #17 CS10 - Eligibility - Children Who Have Access to Public Employee Coverage
Form CMS-10398 #17 CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
Form CMS-10398 #17 CS12 - Eligibility - Dental Only Supplemental Coverage
Form CMS-10398 #17 CS13 - Eligibility - Deemed Newborns
Form CMS-10398 #17 CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
Form CMS-10398 #15 CS15 - MAGI-Based Income Methodologies
Form CMS-10398 #17 CS16 - Other Eligibility Criteria - Spenddowns
Form CMS-10398 #17 CS17 - Non-Financial Eligibility – Residency
Form CMS-10398 #17 CS19 - Non-Financial Eligibility - Social Security Number
Form CMS-10398 #17 CS20 - Non-Financial Eligibility - Substitution of Coverage
Form CMS-10398 #17 CS21 - Non-Financial Eligibility - Non-Payment of Premiums
Form CMS-10398 #17 CS23 - Non-Financial Requirements - Other Eligibility Standards
Form CMS-10398 #17 CS24 - General Eligibility - Eligibility Processing
Form CMS-10398 #17 CS27 - Non-Financial Requirements - Other Eligibility Standards
Form CMS-10398 #17 CS28 - General Eligibility - Presumptive Eligibility for Children
Form CMS-10398 #17 CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women
Form CMS-10398 #17 CS7 - Eligibility - Targeted Low-Income Children
GenIC #18 (Extension w/o change): Alternative Benefit Plans New 56 448 0 Form and Instruction CMS-10398 #18 Mock-up of Interim Form for Alternative Benefit Plans
GenIC #2 (Extension w/o change): Medicaid Managed Care Data Collection New 56 2240 0 Instruction
Instruction
GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment New 40 160 0 Form and Instruction CMS-10398 #21 SPA Attachments: Threshold Methodology for Identification of Applicable FMAP Rates
Instruction
GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10398 #22 Health Homes Administrative Component
Form CMS-10398 #22 Health Home State Plan Amendment
GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers New 56 2240 0 Instruction
Form and Instruction CMS-10398 #24 II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
Instruction
Form and Instruction CMS-10398 #24 IV - Clinic Upper Payment Limit (UPL) Guidance
Instruction
Form and Instruction CMS-10398 #24 Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
Instruction
Form and Instruction CMS-10398 #24 VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction
Form CMS-10398 #24 UPL Physician Template
Form CMS-10398 #24 UPL Institute Mental Disease Template 1
Form CMS-10398 #24 UPL Institute Mental Disease Template
Form CMS-10398 #24 XII. Intermediate Care Facilitiy Template
Form CMS-10398 #24 XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template
Form CMS-10398 #24 XIV - Clinic Template
Instruction
Form CMS-10398 #24 IX - Funding Questions
GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template New 56 2240 0 Form and Instruction CMS-10398 #26 Medicaid Adult Core Set Measures Template
GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2 New 56 1120 0 Form and Instruction CMS-10398 #27 Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
GenIC #28 (Extension w/o change): MMIS APD Template NCCI Coding Initiative New 280 840 0 Form and Instruction 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)
GenIC #29 (Extension w/o change): Medicaid Cost Sharing New 10 50 0 Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-10398 #29 Medicaid Premiums and Cost Sharing
GenIC #30 (Extension w/o change): State Reporting Medicaid Payment Suspension New 1040 1040 0
GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans New 48 2016 0 Instruction
Instruction
Form CMS-10398 #31 Sample Template For State Settings’ Analysis
GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) New 2 78 0 Form CMS-10398 #32 Provider-Preventable Conditions Pre Print
Instruction
GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062) New 40 3200 0 Form CMS-10398 #33 FOA Preprint
GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP New 40 3200 0 Form CMS-10398 #34 Title XXI State Plan Template
GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program New 1 75 0 Form and Instruction CMS-10398 #34 Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
Form and Instruction CMS-10398 #34 Crosswalk - Template
Form and Instruction CMS-10398 #34 Track Changes - Template
GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program New 40 5 0 Form and Instruction CMS-10398 #34 Template for Child Health Plan Under Title XXI of The Social Security Act Children’s Health Insurance Program
GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators New 51 765 0 Form CMS-10398 #35 Eligibility and Enrollment Performance Indicators Template
GenIC #37 (Extension w/o change): Managed Care Rate Setting Guidance New 70 280 0 Instruction
GenIC #37 (Rev): Managed Care Rate Setting Guidance New 74 296 0 Other-2017-2018 Medicaid Managed Care Rate Development Guide
Other-2018-2019 Medicaid Managed Care Rate Development Guide
GenIC #37 (Revised): Managed Care Rate Setting Guidance New 61 307 0 Instruction
Instruction
GenIC #37 (Revision) Managed Care Rate Setting Guidance New 46 5 0 Instruction
Instruction
GenIC #43 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services New 121 7490 0 Instruction
Instruction
GenIC #45 (Extension w/o change): Maternal and Infant Health Quality New 112 112 0 Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #1 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #2 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #3 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #4 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #5 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #6 (Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #1 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #2 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #3 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #4 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #5 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #6 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #7 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #8 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #9 (Postpartum Women)
Form CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #10 (Postpartum Women)
GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services New 9 1026 0 Form CMS-10398 #46 1915(i) Template
GenIC #47 (Extension w/o change): Health Home Core Sets New 30 1200 0 Instruction
GenIC #48 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services New 528 1387 0 Instruction
Instruction
Form CMS-10398 #48 Attachment B: Quality Measurement Data Reporting Templates
GenIC #5 (Extension w/o change): Medicaid Payment Suspensions New 56 1120 0 Form CMS-10398 #5 Payment Suspension Screen Shots
GenIC #50 (Extension w/o change): Community First Choice State Plan New 56 560 0 Instruction
Form CMS-10398 #50 Community First Choice (CFC) State Plan pre-print
GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions New 3 450 0 Form and Instruction CMS-10398 #51 Application Certification Statement - Section 1115(a) Extension
Form and Instruction CMS-10398 #51 1115(e) Extension State Certification
Form and Instruction CMS-10398 #51 1115(f) Extension State Certification
Form and Instruction CMS-10398 #51 Extension With Changes Template
Instruction
GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 264 264 0 Form CMS-10398 #52 Section 438.6(c) pre-print
GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 264 5 0 Form CMS-10398 #52 Section 438.6(c) pre-print
Other-Pre-print Example: COVID19
Other-Pre-print Example: Appendix K
GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 132 5 0 Other-Example
Other-Example
Form and Instruction CMS-10398 #52 Section 438.6(c) Preprint
GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols New 49 784 0 Form and Instruction CMS-10398 #53 Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols
Other-SMD Letter 17-003 (Strategies to Address the Opioid Epidemic)
GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests New 99 792 0 Form and Instruction CMS-10398 #54 EVV Good Faith Effort Request Form (Home Health Care Services)
Form and Instruction CMS-10398 #54 EVV Good Faith Effort Request Form (Personal Care Services)
GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid New 56 448 0 Form CMS-10398 #55 State Fee Schedule Drop
Instruction
GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook New 307 1897 0 Form CMS-10398 #56 PMDA Budget Neutrality Workbook Template
Instruction
Instruction
Instruction
GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates New 455 10080 0 Instruction
Instruction
Instruction
Form CMS-10398 #57 1115 SUD Metrics Template
Instruction
Form 1 1115 SUD Monitoring Report Template
Instruction
Instruction
GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations New 80 160 0 Instruction
Instruction
Instruction
Form and Instruction CMS-10398 #59 Implementation Plan Template
Form CMS-10398 #59 Monitoring Report Template
Form and Instruction CMS-10398 #59 Monitoring Report Workbook
Instruction
Instruction
Form CMS-10398 #59 Monitoring Protocol Template
Form and Instruction CMS-10398 #59 Monitoring Protocol Workbook
Instruction
Form and Instruction CMS-10398 #59 Initial Availability Assessment
Instruction
Other-SMDL
GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders New 51 26 0 Form and Instruction CMS-10398 #60 State Technical Assistance Needs Assessment Survey
Instruction
Other-Cover Letter
GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions New 56 168 0 Instruction
Form CMS-10398.GenIC#61 CMS-10398.GenIC#61 - Medicaid Disaster Relief SPA Template
GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act New 60 840 0 Form CMS-10398 #62 Quarterly Progress Report (QPR) Template
Instruction
GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template New 12 70 0 Form CMS-10120 1932(a) State Plan Amendment Template
GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations New 54 162 0 Other-Introductory Email: Demonstration Characteristics Interview
Other-Confirmation Email: Demonstration Characteristics Interview
Other-Outlook Invitation: Demonstration Characteristics Interview
Other- Reminder Email: Demonstration Characteristics Interview
Other-Introductory Email: Implementation Interview
Other- Email Invitation: Implementation Interview
Other-Confirmation Email: Implementation Interview
Other-Implementation Interview
Other- Reminder Email: Implementation Interview
Form and Instruction CMS-10398 #64 Demonstration Characteristics Interview Email Invitation and Grid
Form and Instruction CMS-10398 #64 Demonstration Characteristics Interview Questions
Form and Instruction CMS-10398 #64 Implementation Interview Protocol with Instructions for Interviewer
GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT) New 66 4485 0 Form CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Attachment 3.1-A)
Form CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Attachment 3.1-B)
GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final New 202 3388 0 Form and Instruction CMS-10398 #7 Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template
Form and Instruction CMS-10398 #7 Cycle Vb. Connecting Kids to Coverage Final Report Template
Form and Instruction CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)
Form and Instruction CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates) New 1634 5258 0 Form CMS-10398 #7 HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qualitative report)
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Final Report Template (qualitative report)
Form CMS-10398 #7 MACRA Cycle Vb, Round III: Final Report Template
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other (quantitative reporting)
Form CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report (quantitative reporting)
GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program New 56 2240 0 Form and Instruction CMS-10398 #9 Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 7822 87060 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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