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) Benefit Specifications and Provider Qualifications
Form CMS-10398 (#10) Budget Neutrality Form
Form and Instruction CMS-10398 (#10) Demonstration Financing Form
Instruction
Form CMS-10398 (#10) Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2
Instruction
Form and Instruction CMS-10398 (#10) Long Term Services and Supports Form
Instruction
Instruction
Form CMS-10398 (#10) Long Term Services Benefit Specifications and Provider Qualifications
Instruction
#11: MAGI-Based Eligibility Verification Plan New 56 2240 0 Form CMS-10398 (#11) MAGI-Based Eligibility Verification Plan
#12: Increase in Primary Care Services Payments New 51 2448 0 Form CMS-10398 (#12) Reimbursement Template - Physician Services
#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Form CMS-10398 (#13) Inpatient Hospital UPL Guidance
Instruction
Instruction
Form CMS-10398 (#13) Nursing Facility UPL Guidance
Instruction
Form CMS-10398 (#13) Outpatient Hospital UPL Guidance
Instruction
#14: MAGI Conversion Plan New 56 1120 0 Form and Instruction CMS-10398 (#14) Modified Adjusted Gross Income (MAGI) Conversion Plan
#15: Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10398 (#15) Medicaid Administration: State Plan Administration/ Designation and Authority
Form CMS-10398 (#15) Medicaid Eligibility: MAGI-Based Income Methodologies
Form CMS-10398 (#15) Medicaid Eligibility: AFDC Income Standards
Form CMS-10398 (#15) Medicaid Eligibility: Presumptive Eligibility by Hospitals
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Pregnant Women
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Adult Group
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility State Residency
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
Form CMS-10398 (#15) Medicaid Eligibility: General Eligibility Requirements Eligibility Process
#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) Eligibility for Medicaid Expansion Program
Form CMS-10398 (#17) Eligibility - Targeted Low-Income Pregnant Women
Form CMS-10398 (#17) Eligibility - Coverage From Conception to Birth
Form CMS-10398 (#17) Eligibility - Deemed Newborns
Form CMS-10398 (#17) Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
Form CMS-10398 (#17) MAGI-Based Income Methodologies
Form CMS-10398 (#17) Non-Financial Eligibility – Residency
Form CMS-10398 (#17) Non-Financial Eligibility – Citizenship
Form CMS-10398 (#17) Non-Financial Eligibility - Social Security Number
Form CMS-10398 (#17) General Eligibility - Eligibility Processing
Form CMS-10398 (#17) Eligibility - Children Who Have Access to Public Employee Coverage
Form CMS-10398 (#17) Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
Form CMS-10398 (#17) Eligibility - Dental Only Supplemental Coverage
Form CMS-10398 (#17) Other Eligibility Criteria - Spenddowns
Form CMS-10398 (#17) Non-Financial Eligibility - Substitution of Coverage
Form CMS-10398 (#17) Non-Financial Eligibility - Non-Payment of Premiums
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Children
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Pregnant Women
Form CMS-10398 (#17) Template CS7 – Targeted Low-Income Child
#18: Alternative Benefit Plans New 56 448 0 Form CMS-10398 (#18) Interim Form for Alternative Benefit Plans
#19: Eligibility and Enrollment Performance Indicators New 612 12240 0 Form CMS-10398 (#19) Monthly Report
#1: CHIP Annual Report Template System (CARTs) New 56 2240 0 Form CMS-10398 (#1) FRAMEWORK FOR THE ANNUAL REPORT
#20: Payment Error Rate Measurement (PERM) Pilot New 52 1120 0 Form and Instruction CMS-10398 (#20) CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission
Form and Instruction CMS-10398 (#20) CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission
Other-SHO Letter
#21: FMAP Claiming State Plan Amendment New 40 160 0 Instruction
Form CMS-10398 (#21) Threshold Methodology for Identification of Applicable FMAP Rates
#22: Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10398 (#22) Health Homes Administrative Report
Form CMS-10398 (#22) Health Home State Plan Amendment
#23: Medicaid Primary Care Payment Increase – State Data Collection Tool New 52 2080 0 Form CMS-10398 (#23) Medicaid Primary Care Payment Increase – State Data Collection Tool
#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) Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)
#26: Medicaid Adult Core Set Measures Reporting Template in CARTS New 56 2240 0 Form and Instruction 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 New 56 1120 0 Form and Instruction CMS-10398 (#27) Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan
#28: MMIS APD Template NCCI Coding Initiative (CMS-10358) New 280 840 0 Form and Instruction 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) New 10 50 0 Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-R-53 Medicaid Premiums and Cost Sharing
#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) 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) New 2 78 0 Instruction
Form 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) New 40 3200 0 Form 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) New 40 3200 0 Form 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 New 51 765 0 Form CMS-10398 (#35) Eligibility and Enrollment Performance Indicators Template
#36: Same Sex Marriage Policy New 56 56 0 Form CMS-10398 (#36) DOMA Medicaid Eligibility SPA Template
Form CMS-10398 (#36) DOMA CHIP Eligibility SPA Template
#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) 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 New 56 1120 0 Form CMS-10398 (#3) RACs At-A-Glance Phase II Data Collection
#4: State Medicaid Recovery Audit Contractor (RAC) Programs, at a Glance (Phase III) New 56 1120 0 Form CMS-10398 (#4) RAC Phase III Reporting
#5: Medicaid Payment Suspensions New 56 1120 0 Form CMS-10398 (#5) Medicaid Payment Suspensions
#6: Medicaid Buy In Payment Suspensions New 35 700 0 Form and Instruction 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 New 4 80 0 Form CMS-10398 (#7) Reporting Template
#7: CHIPRA Cycle II Outreach and Enrollment Grant New 78 1560 0 Form and Instruction CMS-10398 (# 7) CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report
#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) 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) New 9 1026 0 Instruction
Form CMS-10398 (#13) Nursing Facility UPL Guidance
Instruction
Form CMS-10398 (#13) Outpatient Hospital UPL Guidance
Instruction
Form CMS-10398 (#13) Inpatient Hospital UPL Guidance
Form and Instruction CMS-10398 (#13) Nursing Facility UPL Template
Form and Instruction CMS-10398 (#13) Outpatient Hospital UPL Template
Form and Instruction CMS-10398 (#13) Inpatient Hospital UPL Template
Instruction
Form CMS-10398 (#24) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
Instruction
Form CMS-10398 (#24) Clinic Upper Payment Limit (UPL) Guidance
Instruction
Form CMS-10398 (#24) Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
Instruction
Instruction
Form CMS-10398 (#24) Funding Questions
Form and Instruction CMS-10398 (#24) Medicaid Qualified Practitioner Services (Physician) Standard Template
Form and Instruction CMS-10398 (#24) Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template
Form and Instruction CMS-10398 (#24) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template
Form and Instruction CMS-10398 (#24) Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template
Form and Instruction CMS-10398 (#24) Clinic Standard Template
Form CMS-10398 (#46) 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) New 198 18112 0 Instruction
Form CMS-10398 (#45) (Screen 1, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 2, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 3, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 4, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 5, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 6, Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 1, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 2, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 3, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 4, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 5, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 6, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 7, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 8, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 9, Postpartum Women) MIH Initiative Developmental Measure
Form CMS-10398 (#45) (Screen 10, Postpartum Women) MIH Initiative Developmental Measure
Instruction
Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting) New 97 138 0 Form and Instruction CMS-10398 (#7) Cycle III Semi-Annual Report Template
Form and Instruction CMS-10398 (#7) Cycle IV Semi-Annual Report Template
Form and Instruction CMS-10398 (#7) Cycle III Final Report Addendum
Form CMS-10398 (#41) 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) New 127 1867 0 Form CMS-10398 (#7) CHIPRA Cycle III - Semi-Annual Report Template
Form CMS-10398 (#7) CHIPRA Cycle IV - Semi-Annual Report Template
Other-39 State Selection Memo
Form CMS-10398 (#39) 39 Protocol for BHP States
Form CMS-10398 (#39) 39 Protocol for Coverave States
Form CMS-10398 (#39) 39 Protocol for DA States
Form CMS-10398 (#39) 39 Protocol for EI States
Form CMS-10398 (#39) 39 Protocol for FFM States
Form CMS-10398 (#40) 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 New 497 3192 0 Instruction
Instruction
Other-37 - Crosswalk
Form CMS-10398 (#50) Community First Choice (CFC) Template
Form CMS-10398 (#52) Section 438.6(c) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products
Form and Instruction CMS-10398 (#7) • Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)
Form and Instruction CMS-10398 (#7) Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum
Form and Instruction CMS-10398 (#7) Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template
Form and Instruction CMS-10398 (#7) Cycle Vb. Connecting Kids to Coverage Final Report Template
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 Community First Choice (CFC) State Plan Option Preprint
Instruction
Form and Instruction CMS-10398 #51 #51 - Section 1115 Demonstration FAST TRACK Extension Template for Program Changes
Form and Instruction CMS-10398 #51 #51 - 1115(a) Extension State Certification
Form and Instruction CMS-10398 #51 #51 - 1115(e) Extension State Certification
Form and Instruction CMS-10398 #51 #51 - 1115(f) Extension State Certification
GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398) New 121 7490 0 Form CMS-10398 (#43) CCMHC Cost Report
Instruction
Form and Instruction CMS-10398 (#43) 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) New 2 160 0 Form 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 New 56 14 0 Form and Instruction 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 New 528 22192 0 Instruction
Instruction
Form and Instruction CMS-10398 (#48) Quality Measurement Data Reporting Templates
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 Testing Protocol
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  
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