View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0938-1148
ICR Reference No:
202409-0938-028
Status:
Active
Previous ICR Reference No:
202401-0938-016
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMCS
Title:
[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/03/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/27/2024
Terms of Clearance:
OMB is approving this information collection request for a period of three years during which time the agency the agency will submit individual collections under this generic clearance for approval. CMS should consider the timeliness of steps required to continue this collection before the end of this three year OMB approval. This information collection replaces the collections covered under emergency collection (CMS-10398, OMB 0938-1148) which will be discontinued shortly to prevent duplication.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2027
36 Months From Approved
Responses
19,623
0
0
Time Burden (Hours)
450,000
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.
Authorizing Statute(s):
Statute at Large:
21 Stat. 2101
Statute at Large:
21 Stat. 1115
Statute at Large:
19 Stat. 1901
Statute at Large:
19 Stat. 1915
Citations for New Statutory Requirements:
Statute at Large: 19 Stat. 1915
Statute at Large: 21 Stat. 2101
Statute at Large: 21 Stat. 1115
Statute at Large: 19 Stat. 1901
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
89 FR 50333
06/13/2024
30-day Notice:
Federal Register Citation:
Citation Date:
89 FR 68619
08/27/2024
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
22
IC Title
Form No.
Form Name
GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template
GenIC #66, GenIC #66, GenIC #66
Compliance Assessment and Plan for Federal Medicaid and CHIP Renewal Requirements Template
,
Eligibility Processing Data Report portal screen shots
,
Eligibility Processing Data Report excel workbook
GenIC #82 (unchanged from MACPro): Quality Improvement Affinity Group Expression of Interest Form
GenIC #82
Quality Improvement Affinity Group Expression of Interest Form
GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution
Attachment 3.1-M pages 1 and 2, Attachment 3.1-M page 3, Supplement to Attachment 3.1
Attestation for Mandatory Coverage of Eligible Juveniles
,
Attestation for Optional Coverage of Eligible Juveniles
,
Targeted Case Management (TCM) for Mandatory Coverage of Eligible Juveniles
GenIC #87 (New): Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template
CMS-10398 #87
Managed Care Plan (MCP) Medical Loss Ratio (MLR) Reporting Template
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
CMS-10398 #93
Attachment 3.1-L-SUD/IMD (SPA Templates)
Reinstatement of Previously Approved GenICs
Misc (see spreadsheet)
Misc (see spreadsheet)
[Medicaid] GenIC #56 (Revised): Section 1115 Demonstration: Budget Neutrality Monitoring Workbook
GenIC #56, GenIC #56
PMDA Budget Neutrality Monitoring Workbook
,
State User Budget Neutrality Playbook
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility
CS15, CS11, CS3, CS7, CS8, CS9, CS10, CS12, CS13, CS14, CS16, CS17, CS18, CS19, CS20, CS21, CS23, CS24, CS27, CS28, CS29, CS31
Eligibility for Medicaid Expansion Program
,
Eligibility - Targeted Low-Income Children
,
Eligibility - Targeted Low-Income Pregnant Women
,
Eligibility - Coverage From Conception to Birth
,
Eligibility - Children Who Have Access to Public Employee Coverage
,
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
,
Eligibility - Dental Only Supplemental Coverage
,
Eligibility - Deemed Newborns
,
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
,
MAGI-Based Income Methodologies
,
Other Eligibility Criteria – Spenddowns
,
Non-Financial Eligibility – Residency
,
Non-Financial Eligibility – Citizenship
,
Non-Financial Eligibility - Social Security Number
,
Non-Financial Eligibility - Substitution of Coverage
,
Non-Financial Eligibility - Non-Payment of Premiums
,
Non-Financial Requirements - Other Eligibility Standards
,
General Eligibility - Eligibility Processing
,
General Eligibility – Continuous Eligibility
,
General Eligibility - Presumptive Eligibility for Children
,
General Eligibility - Presumptive Eligibility for Pregnant Women
,
General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #17 (revision): CHIP State Plan Eligibility
CS15, CS16, CS14, CS17, CS18, CS19, CS20, CS21, CS23, CS24, CS27, CS28, CS29, CS31, CS3, CS7, CS8, CS9, CS10, CS11, CS12, CS13
Eligibility for Medicaid Expansion Program
,
Eligibility - Targeted Low-Income Children
,
Eligibility - Targeted Low-Income Pregnant Women
,
Eligibility - Coverage From Conception to Birth
,
Eligibility - Children Who Have Access to Public Employee Coverage
,
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
,
Eligibility - Dental Only Supplemental Coverage
,
Eligibility - Deemed Newborns
,
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
,
MAGI-Based Income Methodologies
,
Other Eligibility Criteria – Spenddowns
,
Non-Financial Eligibility – Residency
,
Non-Financial Eligibility – Citizenship
,
Non-Financial Eligibility - Social Security Number
,
Non-Financial Eligibility - Substitution of Coverage
,
Non-Financial Eligibility - Non-Payment of Premiums
,
Non-Financial Requirements - Other Eligibility Standards
,
General Eligibility - Eligibility Processing
,
General Eligibility – Continuous Eligibility
,
General Eligibility - Presumptive Eligibility for Children
,
General Eligibility - Presumptive Eligibility for Pregnant Women
,
General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #37 (Revised) Medicaid Managed Care Rate Development Guide
[Medicaid] GenIC #37 (Revised): Medicaid Managed Care Rate Development Guide
[Medicaid] GenIC #43 (Revision): Certified Community Behavioral Health Clinic (CCBHC) Cost Report
CMS-10398 #43
CCBHC Cost Report
[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application
GenIC #45, GenIC #45
Demonstration Application
,
Compliance Checklist
[Medicaid] GenIC #64 (Revision) Medicaid Section 1115 Substance Use Disorder (SUD) Demonstrations: Federal Meta Analysis
1d, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 3h, 3i, 3j, 4a, 4b, 4c, 4d, 4e, 4f, 4g, 1e, 1f, 1g, 1a, 1c, 1b
Characteristics/Implementation Introductory Email
,
Characteristics/Implementation Interview Email Invitation with Program Characteristics Grid
,
Interview Questions
,
Characteristics/Implementation Confirmation Email
,
Characteristics/Implementation Interview Invitation
,
Characteristics/Implementation Interview Reminder Email
,
Characteristics/Implementation Interview Thank You Email
,
MCO and Behavioral Health Stakeholder Interview Introductory Email
,
MCO and Behavioral Health Provider Stakeholder Interview Introductory Email
,
MCO and Behavioral Health Provider Stakeholder Interview Introductory Email
,
MCO and Behavioral Health Provider Stakeholder Interview Email Invitation
,
MCO and Behavioral Health Provider Stakeholder Interview Outlook Invitation
,
MCO and Behavioral Health Provider Stakeholder Interview Confirmation Email
,
MCO Protocol with Instructions
,
Behavioral Health Stakeholder Interview Protocol with Instructions (Residential Providers)
,
Behavioral Health Stakeholder Interview Protocol with Instructions (Non-Residential Providers)
,
MCO and Behavioral Health Provider Stakeholder Interview Thank You Email
,
Follow-Up Implementation Interview Introductory Email
,
Follow-Up Implementation Interview Email Invitation
,
Follow-Up Implementation Interview Confirmation Email
,
Follow-Up Implementation Interview Outlook Invitation
,
Follow-Up Implementation Interview Reminder Email
,
Follow-Up Implementation Interview Protocol with Instructions
,
Follow-Up Implementation Interview Thank You Email
[Medicaid] GenIC #68 (Revised): SPA Template for 1905(a)(29) of the SSA Medication Assisted Treatment (MAT)
CMS-10398 #68
SPA Attachment 3.1: Section 1905(a)(29) Medication Assisted Treatment (MAT)
[Medicaid] GenIC #83 (New) PACE SPA Preprint
#83
PACE SPA Preprint
[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide
Appendix B
PACE AWOP & Rate Package Submission Cover Sheet
[Medicaid] GenIC #86 (New) Section 1115 Reentry Demonstration Initiative
GenIC #86, GenIC #86, GenIC #86
Reentry Demonstration Initiative Preprint
,
Reentry Implementation Plan Template
,
Reentry Budget Neutrality Formulation Workbook
[Medicaid] GenIC #88 (New): Medicaid/CHIP School-Based Services (SBS) Grants
CMS-10398 #88
SBS Grant Data Submission and TAC Participation Form
[Medicaid] GenIC #90 (New): CAA of 2024, Section 206 Planning Grant Reporting
[Medicaid] GenIC #91 (New): State Plan Amendment (SPA) Template for Medicaid Clinic Benefit
Supplement to Attachment 3.1
State Plan Amendment (SPA) Template for Medicaid Clinic Benefit
[Medicaid] GenIC #94 (New): Streamlining Medicaid Enterprise Systems (MES) Advance Planning Documents (APD) Templates
GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94, GenIC #94
MES APD Template
,
MES OAPD Template
,
AoA Template
,
MES MDBT+CHIP Template
,
MES RFP Checklist
,
Operational Report Workbook
,
MES Project Status Report
,
Intake Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
19,623
0
0
0
0
19,623
Annual Time Burden (Hours)
450,000
0
0
0
0
450,000
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Yes
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
09/27/2024
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