Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions New 112 2240 0 Form CMS-10398-004
Form CMS-10398-005
BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26) New 56 6205 0 Form and Instruction CMS-10398
Form and Instruction CMS-10398
Form and Instruction CMS-10398
Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21) New 52 2240 0 Form CMS-10398 (#20)
Instruction
Form CMS-10398 (#21)
Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26) New 56 2352 0 Form CMS-10398 (#25)
Form and Instruction CMS-10398 (#26)
Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24) New 160 6720 0 Form CMS-10398 (#22)
Form CMS-10398 (#22)
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-10398 (#23)
Instruction
Instruction
Form CMS-10398 (#23)
Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments New 107 4688 0 Form and Instruction CMS-10398 #11
Form CMS-10398 #12
Bundle: (GenIC 1) Medicaid Buy In, (GenIC 2) CNIPRA Cycle II, and (GenIC 3) PIE Transaction New 169 3380 0 Form and Instruction CMS-10398-007
Form and Instruction CMS-10398-006
Instruction
Instruction
Form and Instruction CMS-10398-008
Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application New 112 4480 0 Instruction
Form and Instruction CMS-10398-009
Form CMS-10398-10
Other-1115 Demo - Information on Cost Sharing Requirements
Form CMS-10398-10
Form CMS-10398-10
Form and Instruction CMS-10398-10
Form and Instruction CMS-10398-10
Other-1115 Demo - List of Medicaid Eligibility Groups
Other-1115 Demo - List of Medicaid and CHIP Benefits
Form CMS-10398-10
Form CMS-10398-10
Bundle: PERM Pilot (#20), Same Sex Marriage (#36), and Managed Care Rate Setting (#37) New 50 0 0 Form and Instruction CMS-10398 (#20)
Form and Instruction CMS-10398 (#20)
Form CMS-10398 (#36)
Form CMS-10398 (#36)
Instruction
Bundle: Performance Indicators (# 19), Payment Suspension (# 30), and 1115 Demo (# 38) New 1663 11487 0 Form CMS-10398 (#19)
Form CMS-10398 (#38)
CHIP Annual Report Template System (CARTs) New 168 5600 0 Form CMS-10398-001
Form and Instruction CMS-10398-002
Form and Instruction CMS-10398-002
Form CMS-10398-003
CHIP State Plan Eligibility (ICR #17) New 56 2800 0 Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
Other-CHIP Eligibility State Plan Templates
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7) New 4 80 0 Form and Instruction CMS-10398 (#7)
Collection # 16: Federally-Facilitated Marketplace Integration Data Collection Tool New 56 1120 0 Form CMS-10398
Collection #15 Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Form CMS-10398
Eligibility and Enrollment Performance Indicators (Collection #19 ) New 56 2240 0 Other-Template
Information Collection #18: Alternative Benefit Plans New 56 448 0 Form CMS-10398 (#18)
MAGI Conversion Plan (Information Collection #14 ) New 56 1120 0 Form and Instruction CMS-10398 (#14)
MAGI Conversion Plan Part 2 (GenIC #27) New 56 1120 0 Form and Instruction CMS-10398 (#27)
MMIS APD Template NCCI Coding Initiative (Information Collection #28) New 280 840 0 Form CMS-10398 (#28)
Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Instruction
Instruction
Form CMS-10398 (13)
Form CMS-10398 (13)
Form CMS-10398 (13)
Instruction
Medicaid Premiums and Cost Sharing (#29) New 10 50 0 Form CMS-10398 (#29)
Instruction
Instruction
Instruction
Instruction
Instruction
Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33) New 42 3278 0 Form CMS-10398 (#32)
Instruction
Form CMS-10398 (#33)
Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415 New 1 0 0 Other-
Statewide HCBS Transition Plans (# 31) New 48 2016 0 Form CMS-10398 (#31)
Instruction
Instruction
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 3538 67864 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
To view an IC, click on IC Title