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
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
202103-0938-018
Status:
Historical Active
Previous ICR Reference No:
201712-0938-019
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMCS
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:
04/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
03/23/2021
Terms of Clearance:
We thank CMS for agreeing to submit a subsequent GenIC that includes all public comments, CMS' response to these comments, and any necessary GenIC changes in the case of a GenIC's related to SMDs and SHOs.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2024
36 Months From Approved
04/30/2021
Responses
6,720
0
6,720
Time Burden (Hours)
154,104
0
154,104
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:
21 Stat. 2101
Statute at Large:
19 Stat. 1901
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:
85 FR 37456
06/22/2020
30-day Notice:
Federal Register Citation:
Citation Date:
86 FR 14927
03/19/2021
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
29
IC Title
Form No.
Form Name
#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits
CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13, CMS-10398 #13
MACFIN_inpatient-upl-template
,
MACFIN_outpatient-upl-template
,
MACFIN_nursing-facility-upl-template
,
Guidance Questions: Inpatient
,
Guidance Questions: Nursing
,
Guidance Questions: Outpatient
#17 (Revision): CHIP State Plan Eligibility
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 Children
,
Eligibility - Targeted Low-Income Pregnant Women
,
Eligibility - Coverage From Conception to Birth
,
Eligibility - Children Who Have Access to Public Employee Coverage
,
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
,
Eligibility - Dental Only Supplemental Coverage
,
Eligibility - Deemed Newborns
,
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
,
MAGI-Based Income Methodologies
,
Other Eligibility Criteria – Spenddowns
,
Non-Financial Eligibility – Residency
,
Non-Financial Eligibility – Citizenship (Reinstatement)
,
Non-Financial Eligibility - Social Security Number
,
Non-Financial Eligibility - Substitution of Coverage
,
Non-Financial Eligibility - Non-Payment of Premiums
,
Non-Financial Requirements - Other Eligibility Standards
,
General Eligibility - Eligibility Processing
,
Non-Financial Requirements - Other Eligibility Standards (Revised)
,
General Eligibility - Presumptive Eligibility for Children
,
General Eligibility - Presumptive Eligibility for Pregnant Women
#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs
CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24, CMS-10398 #24
Standard Funding Questions
,
MACFIN_clinic-services-template
,
MACFIN_intermediate-care-upl-template
,
MACFIN_mental-disease-upl-template
,
MACFIN_physician-upl-template
,
MACFIN_prtf-upl-template
,
Guidance Questions_Master File_Clinic
,
Guidance Questions_Master File_ICF IID
,
Guidance Questions_Master File_IMD
,
Guidance Questions_Master File_Physician
,
Guidance Questions_Master File_PRTF
#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials
CMS-10398 #74, CMS-10398 #74, N/A
Att. 3.1-A (Qualifying Clinical Trial Draft Preprint)
,
Att. 3.1.-B (Qualifying Clinical Trial Draft Preprint)
,
Qualifying Clinical Trial Attestation Form
#75 (New): ARP 1135 State Plan Amendment
cms-10398 #75, cms-10398 #75, cms-10398 #75, CMS-10398 #75
Preprint Attachment 7.7A: Vaccine and Vaccine Administration
,
Preprint Attachment 7.7B: COVID-19 Testing
,
Preprint Attachment 7.7C: COVID-19 Treatment
,
Template for Medicaid Section 1135 Waiver of SPA Submission Requirements
#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template
CMS-10398 #79
COVID-19 Risk Corridor Reconciliation Reporting Template
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7)
CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7), CMS-10398 (GenIC#7)
CMS-10398_GenIC_7-CycleVaSAR508
,
CMS-10398_GenIC_7-CycleVbFinalSAR508
,
CMS-10398_GenIC_7-CycleVbMonthlyReport508
,
CMS-10398_GenIC_7-CycleVbMonthlyReportwAIANTarget
,
CMS-10398_GenIC_7-CycleVbMonthlyReportwTarget
GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations
CMS-10398. GenIC#59, CMS-10398. GenIC #59, CMS-10398. GenIC#59, CMS-10398. GenIC #59, CMS-10398.GenIC#59, CMS-10398. GenIC #59
Implementation Plan Template
,
Monitoring Report Template
,
Monitoring Report Workbook
,
Monitoring Protocol Template
,
Monitoring Protocol Workbook
,
Initial Availability Assessment
GenIC #17 (Revision): CHIP State Plan Eligibility
CS10, CS8, CS3, CS11, CS12, CS14, CS18, CS15, CS16, CS17, CS19, CS20, CS23, CS24, CS27 (Revised), CS28, CS29, CS7, CS9, CS13, CS21
Eligibility for Medicaid Expansion Program
,
Eligibility - Targeted Low-Income Children
,
Eligibility - Targeted Low-Income Pregnant Women
,
Eligibility - Coverage From Conception to Birth
,
Eligibility - Children Who Have Access to Public Employee Coverage
,
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
,
Eligibility - Dental Only Supplemental Coverage
,
Eligibility - Deemed Newborns
,
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
,
MAGI-Based Income Methodologies
,
Other Eligibility Criteria – Spenddowns
,
Non-Financial Eligibility – Residency
,
Non-Financial Eligibility – Citizenship
,
Non-Financial Eligibility - Social Security Number
,
Non-Financial Eligibility - Substitution of Coverage
,
Non-Financial Eligibility - Non-Payment of Premiums
,
Non-Financial Requirements - Other Eligibility Standards
,
General Eligibility - Eligibility Processing
,
General Eligibility – Continuous Eligibility
,
General Eligibility - Presumptive Eligibility for Children
,
General Eligibility - Presumptive Eligibility for Pregnant Women
GenIC #37 (Revision): Managed Care Rate Setting Guidance
GenIC #37 (Revision): Managed Care Rate Setting Guidance
GenIC #37 (revision): Managed Care Rate Setting Guidance
CMS-10398 #37, CMS-10398 #37
2021-2022 Medicaid Managed Care Rate Development Guide
,
2022-2023 Medicaid Managed Care Rate Development Guide
GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates
CMS-10398 #57, CMS-10398 #57, CMS-10398 #57, CMS-10398 #57
Monitoring Protocol Template
,
Monitoring Protocol Workbook
,
Monitoring Report Template
,
Monitoring Report Workbook
GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations
Attachment 4, Attachment 5a, Attachment 5b, Attachment 7a, Attachment 7b, Attachment 8a, Attachment 8b, Attachment 11f, Attachment 12g, Attachment 12h
Implementation Plan Template
,
Monitoring Report Template
,
Monitoring Report Workbook
,
Monitoring Protocol Template
,
Monitoring Protocol Workbook
,
Initial Availability Assessment
,
Annual Availability Assessment
,
Implementation Interview Protocol with Instructions
,
IMD Interview Protocol with Instructions
,
CMHC Interview Protocol with Instruction
GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support
CMS-10398 #64, CMS-10398 $64, CMS-10398 (#64)
MCO Protocol with Instructions
,
Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)
,
Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)
GenIC #64 (Revision): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations
GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports
CMS-10398 #66, CMS-10398 #66, CMS-10398 # 66
Screenshots: Unwinding Data Report
,
Unwinding Data Report Workbook
,
State Renewals Report
GenIC #69 (New): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID-19 Emergency
GenIC #69 (Nonsubstantive Change): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID–19 Emergency
GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment
CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7, CMS-10398 #7
Semi-Annual Report Template
,
Final Report Template
,
HK2019 and HK2020 Monthly Progress Report Template
,
HK2019 Monthly Progress Report with Targets Template
,
HK2022 and HK2023 Monthly Progress Report Template
GenIC #71 (New): Reporting Requirements for State Planning Grants for Qualifying Community-Based Mobile Crisis Intervention Services During the COVID–19 Emergency
GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group
CMS-10398 #72
Expression of Interest Form
GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group
CMS-10398 #72
Expression of Interest Form
GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021
CMS-64, CMS-64, CMS-64
SPVNarr Mockup
,
Payment detail Form Mockup
,
Provider Info Mockup
GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials
CMS-10398 #74, CMS-10398 #74, n/a
Qualifying Clinical Trial Preprint (Attachment 3.1-A)
,
Qualifying Clinical Trial Preprint (Attachment 3.1-B)
,
HHS Qualifying Clinical Trial Attestation Form
GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group
CMS-10398 #76
Maternal and Infant Health Initiative Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Learning Collaborative Affinity Group Expression of Interest Form
GenIC Inventory
GenIc #37 (Revised): Medicaid Managed Care Rate Development Guide (CMS-10398)
[Medicaid] GenIC #34 (Revised): 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-10398 #34
Title XXI State Plan Template
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
6,720
0
0
0
0
Annual Time Burden (Hours)
154,104
154,104
0
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
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
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?
No
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:
03/23/2021
An official website of the United States government
The .gov means it's official.
The site is secure.
