Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum New 51 38 0 Form and Instruction CMS-10398.GenIC#11
Form and Instruction CMS-10398.GenIC#11.
GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs New 54 5 0 Instruction
Form and Instruction CMS-10398 #24
Form and Instruction CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
Instruction
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates New 140 3080 0 Form and Instruction CMS-10398 #58
Form and Instruction CMS-10398 #58
Instruction
Form and Instruction CMS-10398 #58
Instruction
Instruction
Other-SMDL
GenIC # 59 (New) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations New 110 3140 0 Instruction
Instruction
Instruction
Form CMS-10398 #59
Form CMS-10398 $59
Instruction
Form CMS-10398 #59
Instruction
Instruction
Form and Instruction CMS-10398 #59
Form and Instruction CMS-10398 #59
Instruction
Instruction
GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs) New 56 2240 0 Form and Instruction CMS-10398 #1
GenIC #1 (Revised): CHIP Annual Report Template System (CARTS) New 51 5 0 Form # 1
GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS) New 56 5 0 Form and Instruction CMS-10398 #1
GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application New 5 1600 0 Form CMS-10398 #10
Form and Instruction CMS-10398 #10
Form and Instruction CMS-10398 #10
Instruction
Form CMS-10398 #10
Other-List of eligibility Groups
Form CMS-10398 #10
Other-List of Medicaid and CHIP Benefits
Other-List of Frequently Requested Waivers and Expenditure Authorities
Form CMS-10398 #10
Form and Instruction CMS-10398 #10
GenIC #11 (Extension w/o change): MAGI-Based Eligibility Verification Plan New 56 2240 0 Form and Instruction CMS-10398 #11
GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 56 2240 0 Instruction
Form and Instruction CMS-10398 #13
Instruction
Form and Instruction CMS-10398 #13
Form and Instruction CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 54 5 0 Instruction
Form and Instruction CMS-10398 #13
Instruction
Form and Instruction CMS-10398 #13
Instruction
Form and Instruction CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility New 56 1120 0 Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
Form and Instruction CMS-10398 #15
GenIC #16 (Extension w/o change): Federally-Facilitated Marketplace (FFM) Integration Data Collection Tool New 56 1120 0 Form CMS-10398 #16
Form CMS-10398 #16
GenIC #17 (Extension w/o change): CHIP State Plan Eligibility 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 #15
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
GenIC #18 (Extension w/o change): Alternative Benefit Plans New 56 448 0 Form and Instruction CMS-10398 #18
GenIC #2 (Extension w/o change): Medicaid Managed Care Data Collection New 56 2240 0 Instruction
Instruction
GenIC #21 (Extension w/o change): FMAP Claiming State Plan Amendment New 40 160 0 Form and Instruction CMS-10398 #21
Instruction
GenIC #22 (Extension w/o change): Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10398 #22
Form CMS-10398 #22
GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers New 56 2240 0 Instruction
Form and Instruction CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
Instruction
Form and Instruction CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Form CMS-10398 #24
Instruction
Form CMS-10398 #24
GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template New 56 2240 0 Form and Instruction CMS-10398 #26
GenIC #27 (Extension w/o change): MAGI Conversion Plan Part 2 New 56 1120 0 Form and Instruction CMS-10398 #27
GenIC #28 (Extension w/o change): MMIS APD Template NCCI Coding Initiative New 280 840 0 Form and Instruction CMS-10398 #28
GenIC #29 (Extension w/o change): Medicaid Cost Sharing New 10 50 0 Instruction
Instruction
Instruction
Instruction
Instruction
Form CMS-10398 #29
GenIC #30 (Extension w/o change): State Reporting Medicaid Payment Suspension New 1040 1040 0
GenIC #31 (Extension w/o change): Statewide HCBS Transition Plans New 48 2016 0 Instruction
Instruction
Form CMS-10398 #31
GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) New 2 78 0 Form CMS-10398 #32
Instruction
GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062) New 40 3200 0 Form CMS-10398 #33
GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP New 40 3200 0 Form CMS-10398 #34
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 New 1 75 0 Form and Instruction CMS-10398 #34
Form and Instruction CMS-10398 #34
Form and Instruction CMS-10398 #34
GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program New 40 5 0 Form and Instruction CMS-10398 #34
GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators New 51 765 0 Form CMS-10398 #35
GenIC #37 (Extension w/o change): Managed Care Rate Setting Guidance New 70 280 0 Instruction
GenIC #37 (Rev): Managed Care Rate Setting Guidance New 74 296 0 Other-2017-2018 Medicaid Managed Care Rate Development Guide
Other-2018-2019 Medicaid Managed Care Rate Development Guide
GenIC #37 (Revised): Managed Care Rate Setting Guidance New 61 307 0 Instruction
Instruction
GenIC #37 (Revision) Managed Care Rate Setting Guidance New 46 5 0 Instruction
Instruction
GenIC #43 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services New 121 7490 0 Instruction
Instruction
GenIC #45 (Extension w/o change): Maternal and Infant Health Quality New 112 112 0 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
GenIC #46 (Extension w/o change): 1915(i) State Plan Home and Community Based Services New 9 1026 0 Form CMS-10398 #46
GenIC #47 (Extension w/o change): Health Home Core Sets New 30 1200 0 Instruction
GenIC #48 (Extension w/o change): Section 223 Demonstration Programs to Improve Community Mental Health Services New 528 1387 0 Instruction
Instruction
Form CMS-10398 #48
GenIC #5 (Extension w/o change): Medicaid Payment Suspensions New 56 1120 0 Form CMS-10398 #5
GenIC #50 (Extension w/o change): Community First Choice State Plan New 56 560 0 Instruction
Form CMS-10398 #50
GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions New 3 450 0 Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
Form and Instruction CMS-10398 #51
Instruction
GenIC #52 (Extension w/o change): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 264 264 0 Form CMS-10398 #52
GenIC #52 (Revised): Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 264 5 0 Form CMS-10398 #52
Other-Pre-print Example: COVID19
Other-Pre-print Example: Appendix K
GenIC #52 (Revision) - Delivery System and Provider Payment Initiatives Under Medicaid Managed Care Products New 132 5 0 Other-Example
Other-Example
Form and Instruction CMS-10398 #52
GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols New 49 784 0 Form and Instruction CMS-10398 #53
Other-SMD Letter 17-003 (Strategies to Address the Opioid Epidemic)
GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests New 99 792 0 Form and Instruction CMS-10398 #54
Form and Instruction CMS-10398 #54
GenIC #55 (New): Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid New 56 448 0 Form CMS-10398 #55
Instruction
GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook New 307 1897 0 Form CMS-10398 #56
Instruction
Instruction
Instruction
GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates New 455 10080 0 Instruction
Instruction
Instruction
Form CMS-10398 #57
Instruction
Form 1
Instruction
Instruction
GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations New 80 160 0 Instruction
Instruction
Instruction
Form and Instruction CMS-10398 #59
Form CMS-10398 #59
Form and Instruction CMS-10398 #59
Instruction
Instruction
Form CMS-10398 #59
Form and Instruction CMS-10398 #59
Instruction
Form and Instruction CMS-10398 #59
Instruction
Other-SMDL
GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders New 51 26 0 Form and Instruction CMS-10398 #60
Instruction
Other-Cover Letter
GenIC #61 - Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment Template and Instructions New 56 168 0 Instruction
Form CMS-10398.GenIC#61
GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act New 60 840 0 Form CMS-10398 #62
Instruction
GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template New 12 70 0 Form CMS-10120
GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations New 54 162 0 Other-Introductory Email: Demonstration Characteristics Interview
Other-Confirmation Email: Demonstration Characteristics Interview
Other-Outlook Invitation: Demonstration Characteristics Interview
Other- Reminder Email: Demonstration Characteristics Interview
Other-Introductory Email: Implementation Interview
Other- Email Invitation: Implementation Interview
Other-Confirmation Email: Implementation Interview
Other-Implementation Interview
Other- Reminder Email: Implementation Interview
Form and Instruction CMS-10398 #64
Form and Instruction CMS-10398 #64
Form and Instruction CMS-10398 #64
GenIC #68 (New) - Section 1006(b) of the SUPPORT Act: Medicaid Assisted Treatment (MAT) New 66 4485 0 Form CMS-10398 #68
Form CMS-10398 #68
GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final New 202 3388 0 Form and Instruction CMS-10398 #7
Form and Instruction CMS-10398 #7
Form and Instruction CMS-10398 #7
Form and Instruction CMS-10398 #7
GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates) New 1634 5258 0 Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program New 56 2240 0 Form and Instruction CMS-10398 #9
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 7822 87060 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
To view an IC, click on IC Title