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GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations CMCS
 
New
 
Voluntary
 

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.pdf https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ Yes No Printable Only
Instruction Video 2 - Populating and Submitting Monitoring Templates.pdf https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ Yes No Printable Only
Instruction Video 3 - Downloading 1115 Monitoring Report Templates.pdf https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ Yes No Printable Only
Form and Instruction CMS-10398 #59 Implementation Plan Template 4 - Implementation Plan Template (2020 version 3).pdf Yes Yes Fillable Printable
Form CMS-10398 #59 Monitoring Report Template 5a - Monitoring Report Template (2020 version 3).docx Yes Yes Fillable Printable
Form and Instruction CMS-10398 #59 Monitoring Report Workbook 5b - Monitoring Report Workbook (2020 version 3).xlsm Yes Yes Fillable Printable
Instruction 5c - Monitoring Report Instructions (2020 version 3).pdf Yes No Printable Only
Instruction 6 - Monitoring Metrics Technical Specifications (2020 version 3).pdf Yes No Printable Only
Form CMS-10398 #59 Monitoring Protocol Template 7a - Monitoring Protocol Template (2020 version 3).docx Yes Yes Fillable Printable
Form and Instruction CMS-10398 #59 Monitoring Protocol Workbook 7b - Monitoring Protocol Workbook (2020 version 3).xlsx Yes Yes Fillable Printable
Instruction 7c - Monitoring Protocol Instructions (2020 version 3).pdf Yes No Printable Only
Form and Instruction CMS-10398 #59 Initial Availability Assessment 8 - Initial Availability Assessment (2020 version 3).xlsm Yes Yes Fillable Printable
Instruction 9 - HIT Plan Instructions (2020 version 3).pdf Yes No Printable Only
Other-SMDL 10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf Yes No Printable Only

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   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 80 0 80 0 0 0
Annual IC Time Burden (Hours) 160 0 160 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC 59 - Supporting Statement (2020 version 6).docx 12/10/2020
Crosswalks 59 - SMI_Crosswalk.xlsx 12/10/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.