Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
#10: Section 1115 Demonstration and Waiver Application New 56 2240 0 Form CMS-10398 (#10)
Form CMS-10398 (#10)
Form and Instruction CMS-10398 (#10)
Instruction
Form CMS-10398 (#10)
Instruction
Form and Instruction CMS-10398 (#10)
Instruction
Instruction
Form CMS-10398 (#10)
Instruction
#11: MAGI-Based Eligibility Verification Plan New 56 2240 0 Form CMS-10398 (#11)
#12: Increase in Primary Care Services Payments New 51 2448 0 Form CMS-10398 (#12)
#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Form CMS-10398 (#13)
Instruction
Instruction
Form CMS-10398 (#13)
Instruction
Form CMS-10398 (#13)
Instruction
#14: MAGI Conversion Plan New 56 1120 0 Form and Instruction CMS-10398 (#14)
#15: Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
Form CMS-10398 (#15)
#16: Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool New 56 1120 0 Instruction
#17 CHIP State Plan Eligibility (MACPro Templates) New 56 2800 0 Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
Form CMS-10398 (#17)
#18: Alternative Benefit Plans New 56 448 0 Form CMS-10398 (#18)
#19: Eligibility and Enrollment Performance Indicators New 612 12240 0 Form CMS-10398 (#19)
#1: CHIP Annual Report Template System (CARTs) New 56 2240 0 Form CMS-10398 (#1)
#20: Payment Error Rate Measurement (PERM) Pilot New 52 1120 0 Form and Instruction CMS-10398 (#20)
Form and Instruction CMS-10398 (#20)
Other-SHO Letter
#21: FMAP Claiming State Plan Amendment New 40 160 0 Instruction
Form CMS-10398 (#21)
#22: Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10398 (#22)
Form CMS-10398 (#22)
#23: Medicaid Primary Care Payment Increase – State Data Collection Tool New 52 2080 0 Form CMS-10398 (#23)
#24: Medicaid Accountability – Upper Payment Limits New 56 2240 0 Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
#25: Tobacco Cessation Quitline Expenditures New 56 112 0 Form CMS-10398 (#25)
#26: Medicaid Adult Core Set Measures Reporting Template in CARTS New 56 2240 0 Form and Instruction CMS-10398 (#26)
#27: MAGI Conversion Plan Part 2 New 56 1120 0 Form and Instruction CMS-10398 (#27)
#28: MMIS APD Template NCCI Coding Initiative (CMS-10358) New 280 840 0 Form and Instruction CMS-10398 (#28)
#29: Medicaid Cost Sharing (CMS-R-53) New 10 50 0 Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-R-53
#2: Medicaid Managed Care Data Collection New 56 2240 0 Instruction
Instruction
#30: State Reporting Medicaid Payment Suspension New 1040 1040 0
#31: Statewide HCBS Transition Plans New 48 2016 0 Instruction
Instruction
Form CMS-10398 (#31)
#32: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) (CMS-10364) New 2 78 0 Instruction
Form CMS-10398 (#32)
#33: Opportunity for Families of Disabled Children to Purchase Medicaid Coverage for Such Children - DRA 6062 (CMS-10232) New 40 3200 0 Form CMS-10398 (#33)
#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) New 40 3200 0 Form CMS-10398 (#34) (formerly, CMS-R-211)
#35: Eligibility and Enrollment Performance Indicators New 51 765 0 Form CMS-10398 (#35)
#36: Same Sex Marriage Policy New 56 56 0 Form CMS-10398 (#36)
Form CMS-10398 (#36)
#37 (2016 Managed Care Rate Setting Guidance) New 70 140 0 Instruction
Other-Crosswalk
#37: Managed Care Rate Setting Guidance New 70 140 0 Instruction
#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412) New 11 448 0 Form and Instruction CMS-10398 (#38) (formerly, CMS-10412)
#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II New 56 1120 0 Form CMS-10398 (#3)
#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III) New 56 1120 0 Form CMS-10398 (#4)
#5: Medicaid Payment Suspensions New 56 1120 0 Form CMS-10398 (#5)
#6: Medicaid Buy In Payment Suspensions New 35 700 0 Form and Instruction CMS-10398 (#6)
#7 (revised): CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template New 4 80 0 Form CMS-10398 (#7)
#7: CHIPRA Cycle II Outreach and Enrollment Grant New 78 1560 0 Form and Instruction CMS-10398 (# 7)
#8: (PIE) Payer Initiated Eligibility/Benefit Transaction New 56 1120 0 Instruction
Instruction
Instruction
#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program New 56 2240 0 Form CMS-10398 (#9)
Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services) New 9 1026 0 Instruction
Form CMS-10398 (#13)
Instruction
Form CMS-10398 (#13)
Instruction
Form CMS-10398 (#13)
Form and Instruction CMS-10398 (#13)
Form and Instruction CMS-10398 (#13)
Form and Instruction CMS-10398 (#13)
Instruction
Form CMS-10398 (#24)
Instruction
Form CMS-10398 (#24)
Instruction
Form CMS-10398 (#24)
Instruction
Instruction
Form CMS-10398 (#24)
Form and Instruction CMS-10398 (#24)
Form and Instruction CMS-10398 (#24)
Form and Instruction CMS-10398 (#24)
Form and Instruction CMS-10398 (#24)
Form and Instruction CMS-10398 (#24)
Form CMS-10398 (#46)
Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets) New 198 18112 0 Instruction
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Form CMS-10398 (#45)
Instruction
Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting) New 97 138 0 Form and Instruction CMS-10398 (#7)
Form and Instruction CMS-10398 (#7)
Form and Instruction CMS-10398 (#7)
Form CMS-10398 (#41)
Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145) New 127 1867 0 Form CMS-10398 (#7)
Form CMS-10398 (#7)
Other-39 State Selection Memo
Form CMS-10398 (#39)
Form CMS-10398 (#39)
Form CMS-10398 (#39)
Form CMS-10398 (#39)
Form CMS-10398 (#39)
Form CMS-10398 (#40)
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 New 497 3192 0 Instruction
Instruction
Other-37 - Crosswalk
Form CMS-10398 (#50)
Form CMS-10398 (#52)
Form and Instruction CMS-10398 (#7)
Form and Instruction CMS-10398 (#7)
Form and Instruction CMS-10398 (#7)
Form and Instruction CMS-10398 (#7)
Other-7 - Crosswalk
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) New 113 1158 0 Instruction
Form CMS-10398 #50
Instruction
Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398) New 121 7490 0 Form CMS-10398 (#43)
Instruction
Form and Instruction CMS-10398 (#43)
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) New 2 160 0 Form CMS-10398 #34
GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool New 56 14 0 Form and Instruction CMS-10398 (#44)
GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services New 528 22192 0 Instruction
Instruction
Form and Instruction CMS-10398 (#48)
GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews New 48 48 0 Other-Model Online Eligibility Results Page
Form and Instruction CMS-10398 #49
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 5532 120398 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
To view an IC, click on IC Title