Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits New 54 5 0 Form and Instruction CMS-10398 #13
Form and Instruction CMS-10398 #13
Form and Instruction CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
Form CMS-10398 #13
#17 (Revision): CHIP State Plan Eligibility New 56 5 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
#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs New 54 5 0 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 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
#74 (New): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials New 66 61 0 Form CMS-10398 #74
Form CMS-10398 #74
Form and Instruction N/A
#75 (New): ARP 1135 State Plan Amendment New 56 168 0 Form cms-10398 #75
Form cms-10398 #75
Form cms-10398 #75
Form CMS-10398 #75
#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template New 30 90 0 Form and Instruction CMS-10398 #79
Other-Frequently Asked Questions (FAQs)
Other-CMCS Outreach Email
Other-Sample Section 1115 Approval Letter
CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grants (CMS-10398; GenIC #7) New 1973 10102 0 Form and Instruction CMS-10398 (GenIC#7)
Form and Instruction CMS-10398 (GenIC#7)
Form and Instruction CMS-10398 (GenIC#7)
Form and Instruction CMS-10398 (GenIC#7)
Form and Instruction CMS-10398 (GenIC#7)
GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations New 114 3314 0 Form CMS-10398. GenIC #59
Form CMS-10398. GenIC#59
Form and Instruction CMS-10398. GenIC #59
Instruction
Instruction
Form CMS-10398. GenIC#59
Form CMS-10398. GenIC #59
Instruction
Form and Instruction CMS-10398.GenIC#59
Instruction
Instruction
Instruction
Instruction
Instruction
GenIC #17 (Revision): CHIP State Plan Eligibility New 56 5 0 Form CS3
Form CS7
Form CS8
Form CS9
Form CS10
Form CS11
Form CS12
Form CS13
Form CS14
Form CS15
Form CS16
Form CS17
Form CS18
Form CS19
Form CS20
Form CS21
Form CS23
Form CS24
Form CS27 (Revised)
Form CS28
Form CS29
Other-IG_CS3
Other-IG_CS7
Other-IG_CS8
Other-IG_CS9
Other-IG_CS10
Other-IG_CS11
Other-IG_CS12
Other-IG_CS13
Other-IG_CS14
Other-IG_CS15
Other-IG_CS16
Other-IG_CS17
Other-IG_CS18
Other-IG_CS19
Other-IG_CS20
Other-IG_CS21
Other-IG_CS23
Other-IG_CS24
Other-IG_CS27 (Revised)
Other-IG_CS28
Other-IG_CS29
GenIC #37 (Revision): Managed Care Rate Setting Guidance New 2 11 0 Other-2023-2024 Managed Care Rate Guidance
Other-2024-2025 Managed Care Rate Guidance
GenIC #37 (Revision): Managed Care Rate Setting Guidance New 135 135 0 Other-2022-2023 Managed Care Rate Guidance
Other-2023-2024 Managed Care Rate Guidance
GenIC #37 (revision): Managed Care Rate Setting Guidance New 135 5 0 Form and Instruction CMS-10398 #37
Form and Instruction CMS-10398 #37
GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates New 596 5 0 Instruction
Form CMS-10398 #57
Form and Instruction CMS-10398 #57
Instruction
Form CMS-10398 #57
Form and Instruction CMS-10398 #57
Instruction
GenIC #59 (Revision): Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations New 168 1708 0 Other-#1 Video: Overview of the Standardized Monitoring Report Process
Other-#2 Video: Populating and Submitting Monitoring Templates
Other-#3 Video: Downloading 1115 Monitoring Report Templates
Form and Instruction Attachment 4
Form and Instruction Attachment 5a
Form and Instruction Attachment 5b
Other-#5c - Monitoring Report Instructions
Form and Instruction Attachment 7a
Form and Instruction Attachment 7b
Other-Attachment 7c - Monitoring Protocol Instructions
Form and Instruction Attachment 8a
Form and Instruction Attachment 8b
Other-Attachment 9 - HIT Plan Instructions
Other-Attachment 10 - State Medicaid Directors letter (SMDL) #18-011
Other-Attachment 11a - Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Mental Health Agency Director
Other-Attachment 11b - Implementation Interview Email Invitation
Other-Attachment 11c - Implementation Interview Confirmation Email
Other-Attachment 11d - Implementation Interview Outlook Invitation
Other-Attachment 11e - Implementation Interview Reminder Email
Form and Instruction Attachment 11f
Other-Attachment 11g - Implementation Interview Thank You Email
Other-Attachment 12a - IMD and CMHC Stakeholder Interview Introductory Email from CMS to State Medicaid Director
Other-Attachment 12b - IMD and CMHC Provider Stakeholder Interview Introductory Email from RTI to State Medicaid Director
Other-Attachment 12c - IMD and CMHC Provider Stakeholder Interview Introductory Email from State Medicaid Director
Other-Attachment 12d - IMD and CMHC Provider Stakeholder Interview Email Invitation
Other-Attachments 12e - IMD and CMHC Provider Stakeholder Interview Outlook Invitation
Other-Attachment 12f - IMD and CMHC Provider Stakeholder Interview Confirmation Email
Form and Instruction Attachment 12g
Form and Instruction Attachment 12h
Other-Attachment 12i - IMD and CMHC Provider Stakeholder Interview Thank You Email
Other-Attachment 6: Technical Specifications for Monitoring Metrics
GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta-Analysis Support New 90 5 0 Other-Introductory Email (from CMS to State Medicaid Director)
Other-Introductory Email (from RTI to State Medicaid Director)
Other-Introductory Email (from State Medicaid Director)
Other-Interview Email Invitation
Other-Interview Outlook Invitation
Other-Interview Confirmation Email
Form and Instruction CMS-10398 #64
Form and Instruction CMS-10398 $64
Form and Instruction CMS-10398 (#64)
Other-Thank You Email
GenIC #64 (Revision): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations New 340 405 0 Other-Demonstration Characteristics Interview Introductory Email
Other-Demonstration Characteristics Interview Email Invitation with Program Characteristics Grid
Instruction
Other-Demonstration Characteristics Interview Confirmation Email
Other-Demonstration Characteristics Interview Outlook Invitation
Other-Demonstration Characteristics Interview Reminder Email
Other-Implementation Interview Introductory Email from CMS to State Medicaid Director and Single State Substance Abuse Agency Director
Other-Implementation Interview Email Invitation
Other-Implementation Interview Confirmation Email
Other-Implementation Interview Outlook Invitation
Other-Implementation Interview Reminder Email
Instruction
Other-MCO and Behavioral Health Stakeholder Interview Introductory Email from CMS to State Medicaid Director
Other-MCO and Behavioral Health Provider Stakeholder Interview Introductory Email from RTI to State Medicaid Director
Other-MCO and Behavioral Health Provider Stakeholder Interview Introductory Email from State Medicaid Director
Other-MCO and Behavioral Health Provider Stakeholder Interview Email Invitation
Other-MCO and Behavioral Health Provider Stakeholder Interview Outlook Invitation
Other-MCO and Behavioral Health Provider Stakeholder Interview Confirmation Email
Instruction
Instruction
Instruction
Other-MCO and Behavioral Health Provider Stakeholder Interview Thank You Email
GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports New 896 14224 0 Form CMS-10398 #66
Other-Unwinding Data Report Specifications
Form CMS-10398 # 66
Form and Instruction CMS-10398 #66
GenIC #69 (New): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID-19 Emergency New 616 1344 0 Other-SMDL
GenIC #69 (Nonsubstantive Change): Reporting Requirements for Additional Funding for Medicaid HCBS During the COVID–19 Emergency New 616 5 0 Other-SMDL
GenIC #7 (Revision): Connecting Kids to Coverage Outreach and Enrollment New 1365 7826 0 Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
Form CMS-10398 #7
GenIC #71 (New): Reporting Requirements for State Planning Grants for Qualifying Community-Based Mobile Crisis Intervention Services During the COVID–19 Emergency New 160 640 0 Instruction
GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group New 20 140 0 Form and Instruction CMS-10398 #72
Other-Fact Sheet
GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group New 20 5 0 Form CMS-10398 #72
Other-Affinity Group Fact Sheet
GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 New 216 3240 0 Form CMS-64
Form CMS-64
Form CMS-64
GenIC #74 (Revised): Coverage of Routine Patient Cost for Items & Services in Qualifying Clinical Trials New 66 5 0 Form CMS-10398 #74
Form CMS-10398 #74
Form n/a
GenIC #76 (New): Expressions of Interest in the Improving Maternal Health by Reducing Low-Risk Cesarean Delivery Affinity Group New 20 140 0 Form and Instruction CMS-10398 #76
Other-Fact Sheet
GenIC Inventory New 6720 79962 0 Other-Inventory of Currently Approved GenICs
GenIc #37 (Revised): Medicaid Managed Care Rate Development Guide (CMS-10398) New 135 5 0 Instruction
Instruction
[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 New 40 160 0 Form and Instruction CMS-10398 #34
Other-Track Change: Title XXI State Plan Template
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 14815 123725 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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