View Information Collection (IC)

View Information Collection (IC)

Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 (#19) Eligibility and Enrollment Performance Indicator Monthly Report # 19 - MonthlyReportForm-State.pdf Yes Yes Fillable Printable
Form CMS-10398 (#38) Section 1115 Demonstration Application Template Section 1115 Application Template rev 10-23-14 clean.docx Yes Yes Fillable Printable

Health Health Care Services

 

47 0
   
State, Local, and Tribal Governments
 
   66 %

  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 1,663 0 1,663 0 0 0
Annual IC Time Burden (Hours) 11,487 0 11,487 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Suporting Statement #19 - Eligibility and Enrollment Performance Indicators Supporting Statement (#19) Eligibility and Enrollment Performace Indicators [rev 10-23-2014 by OSORA PRA].docx 10/27/2014
Supporting Statement #30 - State Reporting Medicaid Payment Suspension Supporting Statement (# 30) State Reporting Medicaid Payment Suspension [rev 10-23-2014 by OSORA PRA].docx 10/27/2014
Suporting Statement # 38 Supporting Statement 2 (#38) Section 1115 Demonstration Long Term Services rev 10-23-2014 by OSORA PRA.docx 10/28/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.