Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and 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.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
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
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
Documents for IC
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.