Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template New 1400 21056 0 Other-Data Specifications
Form and Instruction GenIC #66
Instruction
Form and Instruction GenIC #66
Form and Instruction GenIC #66
GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form New 20 60 0 Form and Instruction GenIC #82
GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution New 168 4872 0 Form Attachment 3.1-M pages 1 and 2
Form Attachment 3.1-M page 3
Form Supplement to Attachment 3.1
GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template New 470 2350 0 Form and Instruction CMS-10398 #87
GenIC #93 (New): Medicaid 1915(l) State Plan Option to Provide Medical Assistance for Eligible Individuals Who Are Patients in Eligible Institutions for Mental Diseases New 56 1400 0 Form CMS-10398 #93
Reinstatement of Previously Approved GenICs New 6541 80232 0 Form and Instruction Misc (see spreadsheet)
[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook New 159 1106 0 Form and Instruction GenIC #56
Form and Instruction GenIC #56
Instruction
[Medicaid] GenIC #17 (Revised) 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
Form CS28
Form CS29
Form CS31
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
[Medicaid] GenIC #17 (Revised): 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
Form CS28
Form CS29
Form CS31
Other-Introduction to the IG
Other-IG (CS3) Eligibility for Medicaid Expansion Program
Other-IG (CS7) Eligibility - Targeted Low-Income Children
Other-IG (CS8) Eligibility - Targeted Low-Income Pregnant Women
Other-IG (CS9) Eligibility - Coverage From Conception to Birth
Other-IG (CS10) Eligibility - Children Who Have Access to Public Employee Coverage
Other-IG (CS11) Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
Other-IG (CS12) Eligibility - Dental Only Supplemental Coverage
Other-IG (CS13) Eligibility - Deemed Newborns
Other-IG (CS14) Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
Other-IG (CS15) MAGI-Based Income Methodologies
Other-IG (CS16) Other Eligibility Criteria – Spenddowns
Other-IG (CS17) Non-Financial Eligibility – Residency
Other-IG (CS18) Non-Financial Eligibility – Citizenship
Other-IG (CS19) Non-Financial Eligibility - Social Security Number
Other-IG (CS20) Non-Financial Eligibility - Substitution of Coverage
Other-IG (CS21) Non-Financial Eligibility - Non-Payment of Premiums
Other-IG (CS23) Non-Financial Requirements - Other Eligibility Standards
Other-IG (CS24) General Eligibility - Eligibility Processing
Other-IG (CS27) General Eligibility – Continuous Eligibility
Other-IG (CS28) General Eligibility - Presumptive Eligibility for Children
Other-IG (CS29) General Eligibility - Presumptive Eligibility for Pregnant Women
Other-IG (CS31) General Eligibility – Incarcerated CHIP Beneficiaries
[Medicaid] 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
Form CS28
Form CS29
Form CS31
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
[Medicaid] GenIC #37 (Revised) Medicaid Managed Care Rate Development Guide New 137 205 0 Instruction
Instruction
[Medicaid] GenIC #37 (Revised): Medicaid Managed Care Rate Development Guide New 2 1 0 Other-2024-2025 Rate Guide
Other-2024-2025 Rate Guide Addendum
Other-2025-2026 Rate Guide
[Medicaid] GenIC #43 (Revision): Certified Community Behavioral Health Clinic (CCBHC) Cost Report New 440 14419 0 Form CMS-10398 #43
Instruction
Instruction
[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application New 43 194 0 Form and Instruction GenIC #45
Form and Instruction GenIC #45
Other-Guidance on Addition of CCBHCs
Other-Guidance for States Reporting Changes
[Medicaid] GenIC #59 (Revised): Medicaid Section 1115 Severe Mental Illness (SMI) and Children with Serious Emotional Disturbance (SED) Demonstrations New 329 5 0 Other-Video: Overview of the Standardized Monitoring Report Process
Other-Video: Populating and Submitting Monitoring Templates
Other-Video: Downloading 1115 Monitoring Report Templates
Form 4
Form 5a
Instruction
Instruction
Form 5b
Form 7a
Form 7b
Instruction
Form 8b
Instruction
Other-State Medicaid Directors letter (SMDL) #18-011
Form 8a
Form 11a
Form 11b
Form 11c
Form 11d
Form 11e
Form and Instruction 11f
Form 11g
Form 12a
Form 12b
Form 12c
Form 12d
Form 12e
Form 12f
Form and Instruction 12g
Form and Instruction 12h
Form 12i
Form 13a
Form 13b
Form 13c
Form 13d
Form 13e
Form and Instruction 13f
Form 13g
[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis New 384 506 0 Form 1a
Form 1b
Form and Instruction 1c
Form 1d
Form 1e
Form 1f
Form 1g
Form 3a
Form 3b
Form 3c
Form 3d
Form 3e
Form 3f
Form and Instruction 3g
Form and Instruction 3h
Form and Instruction 3i
Form 3j
Form 4a
Form 4b
Form 4c
Form 4d
Form 4e
Form and Instruction 4f
Form 4g
[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT) New 56 1400 0 Form CMS-10398 #68
[Medicaid] GenIC #7(Revised): Connecting Kids to Coverage Outreach and Enrollment New 375 2150 0 Form and Instruction Attachment 1
Form and Instruction Attachment 2
Form and Instruction Attachment 3
[Medicaid] GenIC #83 (New) PACE SPA Preprint New 40 5560 0 Form #83
[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide New 34 17 0 Instruction
Instruction
Form Appendix B
Instruction
[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative New 30 300 0 Form GenIC #86
Instruction
Form and Instruction GenIC #86
Form and Instruction GenIC #86
[Medicaid] GenIC #88 (New): Medicaid/CHIP School-Based Services (SBS) Grants New 114 1278 0 Form and Instruction CMS-10398 #88
[Medicaid] GenIC #90 (New): CAA of 2024, Section 206 Planning Grant Reporting New 300 1200 0 Instruction
Other-Home Page for GrantSolutions
Instruction
[Medicaid] GenIC #91 (New): State Plan Amendment (SPA) Template for Medicaid Clinic Benefit New 56 1400 0 Form Supplement to Attachment 3.1
[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates New 3314 86096 0 Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
Form and Instruction GenIC #94
[Medicaid] GenIC #96 (New): Mental Health (MH) and Substance Use Disorder (SUD) Parity Reporting Tools New 93 6074 0 Form and Instruction CMS-10398 #96
Instruction
Instruction
Form and Instruction CMS-10398 #96
Form and Instruction CMS-10398 #96
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 14729 231896 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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