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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations
Agency IC Tracking Number:
CMCS
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
Other-#1 Video: Overview of the Standardized Monitoring Report Process
Attachment 1. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx
https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/
Yes
No
Printable Only
Other-#2 Video: Populating and Submitting Monitoring Templates
Attachment 2. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx
https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/
Yes
No
Printable Only
Other-#3 Video: Downloading 1115 Monitoring Report Templates
Attachment 3. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx
https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/
Yes
No
Printable Only
Form and Instruction
Attachment 4
Implementation Plan Template
Attachment 4. The Medicaid Section 1115 SMISED Implementation Plan_CLean 508.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 5a
Monitoring Report Template
Attachment 5a. The Medicaid Section 1115 SMISED Demonstration Monitoring Report Template_Clean 508.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 5b
Monitoring Report Workbook
Attachment 5b. The Medicaid Section 1115 SMISED Monitoring WorkbookPlanned Metrics_Clean.xlsx
Yes
Yes
Fillable Fileable
Other-#5c - Monitoring Report Instructions
5c - Monitoring Report Instructions (2020 version 3).pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 7a
Monitoring Protocol Template
Attachment 7a. The Medicaid Section 1115 SMISED Monitoring Protocol Template_Clean 508.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 7b
Monitoring Protocol Workbook
7b - Monitoring Protocol Workbook (2020 version 3).xlsx
Yes
Yes
Fillable Fileable
Other-Attachment 7c - Monitoring Protocol Instructions
7c - Monitoring Protocol Instructions (2020 version 3).pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 8a
Initial Availability Assessment
Attachment 8a - Initial Availability Assessment_Clean.xlsm
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 8b
Annual Availability Assessment
Attachment 8b - Annual Availability Assessment_Clean.xlsm
Yes
Yes
Fillable Fileable
Other-Attachment 9 - HIT Plan Instructions
9 - HIT Plan Instructions (2020 version 3).pdf
Yes
Yes
Fillable Fileable
Other-Attachment 10 - State Medicaid Directors letter (SMDL) #18-011
10 - State Medicaid Directors letter (SMDL) #18-011 (2020 version 3).pdf
No
Printable Only
Other-Attachment 11a - Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director
Attachment 11.a. SMI_SED Demonstration Implementation Interview Introductory email template from CMS to state Medicaid Directors.docx
Yes
Yes
Fillable Fileable
Other-Attachment 11b - Implementation Interview Email Invitation
Attachment 11.b. SMI_SED Demonstration Implementation Interview Email Invitation.docx
Yes
Yes
Fillable Fileable
Other-Attachment 11c - Implementation Interview Confirmation Email
Attachment 11.c. SMI_SED Demonstration Implementation Interview Confirmation Email.docx
Yes
Yes
Fillable Fileable
Other-Attachment 11d - Implementation Interview Outlook Invitation
Attachment 11.d. SMI_SED Demonstration Implementation Interview Outlook Invitation_clean.docx
Yes
Yes
Fillable Fileable
Other-Attachment 11e - Implementation Interview Reminder Email
Attachment 11.e. SMI_SED Demonstration Implementation Interview Reminder email.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 11f
Implementation Interview Protocol with Instructions
Attachment 11.f. SMI_SED Demonstration Implementstion Interview Protocol.docx
Yes
Yes
Fillable Fileable
Other-Attachment 11g - Implementation Interview Thank You Email
Attachment 11.g. SMI_SED Demonstration Implementation Interview Thank you email.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12a - IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director
Attachment 12.a. IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12b - IMD and CMHC Provider Stakeholder Interview Introductory Email from RTI to State Medicaid Director
Attachment 12.b. IMD-CMHC Interview Introductory Email from RTI to SMD_Clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12c - IMD and CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director
Attachment 12.c. IMD-CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director_Clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12d - IMD and CMHC Provider Stakeholder Interview Email Invitation
Attachment 12.d. IMD and CMHC Provider Interview Email Invitation_clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachments 12e - IMD and CMHC Provider Stakeholder Interview Outlook Invitation
Attachment 12.e. IMD and CMHC Provider Stakeholder Interview Outlook Invitation_Clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12f - IMD and CMHC Provider Stakeholder Interview Confirmation Email
Attachment 12.f. IMD and CMHC Provider Stakeholder Interview Confirmation Email_Clean_508.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 12g
IMD Interview Protocol with Instructions
Attachment 12.g. IMD Interview Protocol with Instructions_Clean_508.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 12h
CMHC Interview Protocol with Instruction
Attachment 12.h. CMHC Interview Protocol with Instruction_Clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 12i - IMD and CMHC Provider Stakeholder Interview Thank You Email
Attachment 12.i. IMD and CMHC Provider Stakeholder Interview Thank You Email_Clean_508.docx
Yes
Yes
Fillable Fileable
Other-Attachment 6: Technical Specifications for Monitoring Metrics
6 - Monitoring Metrics Technical Specifications (2020 version 3) (1).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:
65
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
168
0
168
0
0
0
Annual IC Time Burden (Hours)
1,708
0
1,708
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 (2023 version 11).docx
05/23/2023
Public Comment (page 1 of 3)
lhp-vdfz-msa3 - Combined Cover Note and Comment.pdf
05/18/2023
Public Comment (page 2 of 3)
lhp-vdfz-msa3 - Conceptualization Stage of Research.pdf
05/18/2023
Public Comment (page 3 of 3)
lhp-vdfz-msa3 - Stress,Emotion, and Mental Health in African American Men- Final Draft.pdf
05/18/2023
Response to Public Comments
Response To Public Comments.docx
05/18/2023
Crosswalk - Attachment 5b Monitoring Report Workbook
Crosswalk - Attachment 5b Monitoring Report Workbook.xlsx
05/22/2023
Crosswalk Attachment 7b - Monitoring Protocol Workbook
Crosswalk - Attachment 7b Monitoring Protocol Workbook.xlsx
05/22/2023
Crosswalk - Attachment 8b Annual Availability Assessment
Crosswalk - Attachment 8b Annual Availability Assessment.xlsx
05/22/2023
Crosswalk: Attachment 4 - Implementation Plan Template
Crosswalk - Attachment 4 Implementation Plan Template.xlsx
05/23/2023
Crosswalk: Attachment 5a - Monitoring Report Template.xlsx
Crosswalk - Attachment 5a Monitoring Report Template.xlsx
05/23/2023
Crosswalk: Attachment 7a - Monitoring Protocol Template.xlsx
Crosswalk - Attachment 7a Monitoring Protocol Template.xlsx
05/23/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.