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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0938-1148
ICR Reference No:
201410-0938-016
Status:
Historical Active
Previous ICR Reference No:
201111-0938-009
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
12/24/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/30/2014
Terms of Clearance:
Approved consistent with the understanding that individual collections (GenICs) will be submitted for review and approval prior to initiating those collections.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2017
36 Months From Approved
12/31/2014
Responses
6,720
0
3,360
Time Burden (Hours)
154,104
0
86,240
Cost Burden (Dollars)
0
0
0
Abstract:
The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.
Authorizing Statute(s):
Statute at Large:
21 Stat. 1115
Statute at Large:
19 Stat. 1901
Statute at Large:
21 Stat. 2101
Statute at Large:
19 Stat. 1915
Citations for New Statutory Requirements:
Statute at Large: 19 Stat. 1915
Statute at Large: 21 Stat. 2101
Statute at Large: 21 Stat. 1115
Statute at Large: 19 Stat. 1901
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 40105
07/11/2014
30-day Notice:
Federal Register Citation:
Citation Date:
79 FR 62628
10/20/2014
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
51
IC Title
Form No.
Form Name
#10: Section 1115 Demonstration and Waiver Application
CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10), CMS-10398 (#10)
Benefit Specifications and Provider Qualifications
,
Budget Neutrality Form
,
Demonstration Financing Form
,
Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2
,
Long Term Services and Supports Form
,
Long Term Services Benefit Specifications and Provider Qualifications
#11: MAGI-Based Eligibility Verification Plan
CMS-10398 (#11)
MAGI-Based Eligibility Verification Plan
#12: Increase in Primary Care Services Payments
CMS-10398 (#12)
Reimbursement Template - Physician Services
#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits
CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13)
Inpatient Hospital UPL Guidance
,
Nursing Facility UPL Guidance
,
Outpatient Hospital UPL Guidance
#14: MAGI Conversion Plan
CMS-10398 (#14)
Modified Adjusted Gross Income (MAGI) Conversion Plan
#15: Medicaid State Plan Eligibility
CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15), CMS-10398 (#15)
Medicaid Administration: State Plan Administration/ Designation and Authority
,
Medicaid Eligibility: MAGI-Based Income Methodologies
,
Medicaid Eligibility: AFDC Income Standards
,
Medicaid Eligibility: Presumptive Eligibility by Hospitals
,
Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
,
Medicaid Eligibility: Mandatory Coverage Pregnant Women
,
Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
,
Medicaid Eligibility: Mandatory Coverage Adult Group
,
Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
,
Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
,
Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
,
Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
,
Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
,
Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
,
Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
,
Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
,
Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
,
Medicaid Eligibility: Non-Financial Eligibility State Residency
,
Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
,
Medicaid Eligibility: General Eligibility Requirements Eligibility Process
#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool
#17 CHIP State Plan Eligibility (MACPro Templates)
CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17), CMS-10398 (#17)
Eligibility for Medicaid Expansion Program
,
Eligibility - Targeted Low-Income Pregnant Women
,
Eligibility - Coverage From Conception to Birth
,
Eligibility - Deemed Newborns
,
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
,
MAGI-Based Income Methodologies
,
Non-Financial Eligibility – Residency
,
Non-Financial Eligibility – Citizenship
,
Non-Financial Eligibility - Social Security Number
,
General Eligibility - Eligibility Processing
,
Eligibility - Children Who Have Access to Public Employee Coverage
,
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
,
Eligibility - Dental Only Supplemental Coverage
,
Other Eligibility Criteria - Spenddowns
,
Non-Financial Eligibility - Substitution of Coverage
,
Non-Financial Eligibility - Non-Payment of Premiums
,
Non-Financial Requirements - Other Eligibility Standards
,
Non-Financial Requirements - Other Eligibility Standards
,
General Eligibility - Presumptive Eligibility for Children
,
General Eligibility - Presumptive Eligibility for Pregnant Women
,
Template CS7 – Targeted Low-Income Child
#18: Alternative Benefit Plans
CMS-10398 (#18)
Interim Form for Alternative Benefit Plans
#19: Eligibility and Enrollment Performance Indicators
CMS-10398 (#19)
Monthly Report
#1: CHIP Annual Report Template System (CARTs)
CMS-10398 (#1)
FRAMEWORK FOR THE ANNUAL REPORT
#20: Payment Error Rate Measurement (PERM) Pilot
CMS-10398 (#20), CMS-10398 (#20)
CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission
,
CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission
#21: FMAP Claiming State Plan Amendment
CMS-10398 (#21)
Threshold Methodology for Identification of Applicable FMAP Rates
#22: Health Home State Plan Amendment (SPA)
CMS-10398 (#22), CMS-10398 (#22)
Health Homes Administrative Report
,
Health Home State Plan Amendment
#23: Medicaid Primary Care Payment Increase – State Data Collection Tool
CMS-10398 (#23)
Medicaid Primary Care Payment Increase – State Data Collection Tool
#24: Medicaid Accountability – Upper Payment Limits
#25: Tobacco Cessation Quitline Expenditures
CMS-10398 (#25)
Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)
#26: Medicaid Adult Core Set Measures Reporting Template in CARTS
CMS-10398 (#26)
Reporting of the Core Set of Health Care Quality Measures for Medicaid-Eligible Adults (Medicaid Adult Core Set)
#27: MAGI Conversion Plan Part 2
CMS-10398 (#27)
Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
#28: MMIS APD Template NCCI Coding Initiative (CMS-10358)
CMS-10398 (#28)
Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State’s Medicaid Management Information System (MMIS)
#29: Medicaid Cost Sharing (CMS-R-53)
CMS-R-53
Medicaid Premiums and Cost Sharing
#2: Medicaid Managed Care Data Collection
#30: State Reporting Medicaid Payment Suspension
#31: Statewide HCBS Transition Plans
CMS-10398 (#31)
Sample Template For State Settings’ Analysis
#32: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) (CMS-10364)
CMS-10398 (#32)
Pre-print Provider-Preventable Conditions
#33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232)
CMS-10398 (#33)
Family Opportunity Act Preprint
#34: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program (CMS-R-211)
CMS-10398 (#34) (formerly, CMS-R-211)
Template for Child Health Plan Under Title XXI of the Social Security Act, Children’s Health Insurance Program
#35: Eligibility and Enrollment Performance Indicators
CMS-10398 (#35)
Eligibility and Enrollment Performance Indicators Template
#36: Same Sex Marriage Policy
CMS-10398 (#36), CMS-10398 (#36)
DOMA Medicaid Eligibility SPA Template
,
DOMA CHIP Eligibility SPA Template
#37 (2016 Managed Care Rate Setting Guidance)
#37: Managed Care Rate Setting Guidance
#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412)
CMS-10398 (#38) (formerly, CMS-10412)
Section 1115 Demonstration, Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions
#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II
CMS-10398 (#3)
RACs At-A-Glance Phase II Data Collection
#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III)
CMS-10398 (#4)
RAC Phase III Reporting
#5: Medicaid Payment Suspensions
CMS-10398 (#5)
Medicaid Payment Suspensions
#6: Medicaid Buy In Payment Suspensions
CMS-10398 (#6)
The Medicaid Buy-In Program Questionnaire
#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template
CMS-10398 (#7)
Reporting Template
#7: CHIPRA Cycle II Outreach and Enrollment Grant
CMS-10398 (# 7)
CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report
#8: (PIE) Payer Initiated Eligibility/Benefit Transaction
#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
CMS-10398 (#9)
Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)
CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#13), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#24), CMS-10398 (#46)
Nursing Facility UPL Guidance
,
Outpatient Hospital UPL Guidance
,
Inpatient Hospital UPL Guidance
,
Nursing Facility UPL Template
,
Outpatient Hospital UPL Template
,
Inpatient Hospital UPL Template
,
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
,
Clinic Upper Payment Limit (UPL) Guidance
,
Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
,
Funding Questions
,
Medicaid Qualified Practitioner Services (Physician) Standard Template
,
Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template
,
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template
,
Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template
,
Clinic Standard Template
,
1915(i) State Plan Home and Community-Based Services Administration and Operation
Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)
CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45), CMS-10398 (#45)
(Screen 1, Women) MIH Initiative Developmental Measure
,
(Screen 2, Women) MIH Initiative Developmental Measure
,
(Screen 3, Women) MIH Initiative Developmental Measure
,
(Screen 4, Women) MIH Initiative Developmental Measure
,
(Screen 5, Women) MIH Initiative Developmental Measure
,
(Screen 6, Women) MIH Initiative Developmental Measure
,
(Screen 1, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 2, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 3, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 4, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 5, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 6, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 7, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 8, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 9, Postpartum Women) MIH Initiative Developmental Measure
,
(Screen 10, Postpartum Women) MIH Initiative Developmental Measure
Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)
CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#41)
Cycle III Semi-Annual Report Template
,
Cycle IV Semi-Annual Report Template
,
Cycle III Final Report Addendum
,
1095 B Reporting (Conf Call Questions)
Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)
CMS-10398 (#39), CMS-10398 (#39), CMS-10398 (#40), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#39), CMS-10398 (#39), CMS-10398 (#39)
CHIPRA Cycle III - Semi-Annual Report Template
,
CHIPRA Cycle IV - Semi-Annual Report Template
,
39 Protocol for BHP States
,
39 Protocol for Coverave States
,
39 Protocol for DA States
,
39 Protocol for EI States
,
39 Protocol for FFM States
,
40 Sample Balancing Incentive Report
Bundle: #7 (Cycle IV and Cycle V), #37 (Managed Care Rate Setting), #50 (Community First Choice State Plan), and #52 (Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Prod
CMS-10398 (#50), CMS-10398 (#52), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7), CMS-10398 (#7)
Community First Choice (CFC) Template
,
Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products
,
• Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)
,
Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
,
Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template
,
Cycle Vb. Connecting Kids to Coverage Final Report Template
Bundle: GenICs 37 (Managed Care Rate Setting Guidance), 50 (Community First Choice State Plan), and 51 (Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions)
CMS-10398 #51, CMS-10398 #51, CMS-10398 #51, CMS-10398 #50, CMS-10398 #51
Community First Choice (CFC) State Plan Option Preprint
,
#51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes
,
#51 - 1115(a) Extension State Certification
,
#51 - 1115(e) Extension State Certification
,
#51 - 1115(f) Extension State Certification
GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)
CMS-10398 (#43), CMS-10398 (#43)
CCMHC Cost Report
,
State Demonstration Proposal Application and Guidance
GenIC #34: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program (Formerly CMS-R-211)
CMS-10398 #34
Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool
CMS-10398 (#44)
Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules
GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services
CMS-10398 (#48)
Quality Measurement Data Reporting Templates
GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews
CMS-10398 #49
Testing Protocol
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
6,720
3,360
3,360
0
0
0
Annual Time Burden (Hours)
154,104
86,240
67,864
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Yes
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/30/2014
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