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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37)
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10398 (#20)
User Guide - PERM Round 1 Findings Submission
User Guide Round 1 Findings Submission [rev 9-11-2014 by OSORA PRA].docx
Yes
Yes
Fillable Printable
Form and Instruction
CMS-10398 (#20)
User Guide - PERM Round 2 Proposal Submission
User Guide Round 2 Proposal Submission [rev 9-11-2014 by OSORA PRA].docx
Yes
Yes
Fillable Printable
Form
CMS-10398 (#36)
DOMA Same Sex CHIP Template
DOMA CHIP SPA Template [rev 9-11-2014 by OSORA PRA].docx
Yes
Yes
Fillable Printable
Form
CMS-10398 (#36)
DOMA Same Sex Medicaid Template
DOMA SPA Template [rev 9-11-2014 by OSORA PRA].docx
Yes
Yes
Fillable Printable
Instruction
2015 Medicaid Managed Care Rate Guidance 09-3-14.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
50
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
50
0
50
0
0
0
Annual IC Time Burden (Hours)
0
0
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement - PERM Pilot
Supporting Statement - PERM Pilot Rounds 1 and 2 [rev 9-11-2014 by OSORA PRA].docx
09/11/2014
Crosswalk - PERM Round 1 and 2 Proposal Submission
Crosswalk for round 1 and 2 proposal.xlsx
09/11/2014
PERM SHO Letter
StateHealthOfficialLetter (3).pdf
09/11/2014
Supporting Statement - DOMA Same Sex
Supporting Statement (# 36) - Same Sex Marriage rev 9-11-2014 by OSORA.docx
09/11/2014
Supporting Statement - Managed Care Rate Setting
Supporting Statement 2015 Managed Care Rate Setting Guidance.docx
09/11/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.