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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations
Agency IC Tracking Number:
CMCS
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
Video 1 - Overview of the Standardized Monitoring Report Process.docx
https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/
Yes
Yes
Fillable Fileable
Instruction
Video 2 - Populating and Submitting Monitoring Templates.docx
https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/
Yes
Yes
Fillable Fileable
Instruction
Video 3 - Downloading 1115 Monitoring Report Templates.docx
https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/
Yes
Yes
Fillable Fileable
Form
CMS-10398 #59
Implementation Plan Template
4 - smi-impl-plan-template (version 2).pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 $59
Monitoring Report Template
5 - 1115-SMI-Monitoring-Report-Template (version 2).pdf
Yes
Yes
Fillable Fileable
Instruction
6 - 1115_SMI_Metrics_Tech_specs_v1 (version 2).pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #59
Monitoring Protocol Template
7 - 1115-SMI-Monitoring-Protocol-Template (version 2).pdf
Yes
Yes
Fillable Fileable
Instruction
8 - 1115-SMI-Monitoring-Protocol-Template-Instructions (version 2).pdf
Yes
Yes
Fillable Fileable
Instruction
9 - 1115-SMI-Monitoring-Report-Template-Instructions (version 2).pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #59
Monitoring Workbook
10 - 1115-SMI-Monitoring-Workbook_013020 (version 2).xlsm
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #59
Current Availability Assessment
11 - 1115-smi-current-availability-assessment_013020 (version 2).xlsm
Yes
Yes
Fillable Fileable
Instruction
12 - SMI_SED_HIT_Plan_Instructions (version 2).pdf
Yes
Yes
Fillable Fileable
Instruction
13 - smd18011.pdf
No
Printable Only
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:
10
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
110
0
110
0
0
0
Annual IC Time Burden (Hours)
3,140
0
3,140
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Generic Supporting Statement
GenIC #59 - Generic Supporting Statement (version 3).docx
04/21/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.