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Agenda
Reg Review
ICR
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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