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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38)
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
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
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:
47
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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
Documents for IC
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.