Form CMS-10398 (#20) CMS-10398 (#20) PERM Pilot Submission Template

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

PERM Pilot Proposal Submission State Template.xlsx

Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

 Field Description of Field Input Method CMS Review


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Administrative State Name Identify the state Drop Down Box; Choices = all states and DC CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Name of Pilot State titles the proposed pilot Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Pilot Submission Date Date the pilot proposal submitted to CMS Auto generated by PETT website N/A


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Pilot Findings Due Date Date the pilot findings are due to CMS Drop Down Box; Choices = "June 2014"; "December 2014"; "June 2015"; "June 2016" CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































General Information State Agency Responsible for Conducting Review Designate which state agency if conducting the review. Specify if state is hiring contractor to conduct review. Free form text CMS checks for independence


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































State Contact Name Name of the state staff person responsible for responding to CMS questions about the pilots Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































State Contact Email Address Email address of the state staff person responsible for responding to CMS questions about the pilot Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































State Contact Phone Number Phone number of the state staff person responsible for responding to CMS questions about the pilot Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Name of State Agencies That Make Eligibility Determinations Self explanatory Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Pilot Methodology Sampling Frame Description of Sampling Frame Description of the sampling frame of cases from which the sample will be drawn Free form text Sampling frame must include MAGI-based Medicaid and CHIP Eligibility determinations (both active and negative)


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Description of Exclusions Describe any cases that will be excluded from the sampling frame including how beneficiary fraud cases will be addressed (examples of possible exclusions include cases under active fraud investigation, state-only funded cases, Express lane eligibility cases, other cases not matched with Title XIX or XXI funds), including any Administrative Transfers. Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































QC Procedures for Sampling Frame Describe the quality control procedures that will be applied to ensure the completeness/accuracy of the population from which the sample is drawn. Describe how the state will ensure sample does not include exclusions. Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Stratification Specify if the sampling frame will be stratified. States may elect to stratify to ensure representation from particular characteristics Drop Down Box; Choices = "Yes"; "No" CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































(If answer yes to stratification) Description of Strata Describe stratification methodology. Free form text CMS checks for completion and ensure state chooses strata that will allow them to report on required results


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sampling Sample Size Enter the total sample size for the pilot. Free form text CMS checks to ensure sample size meets minimum standards set forth in technical guidance


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sample Program Distribution Describe how the sample will be distributed between Medicaid and CHIP. The distribution should be proportionate to the number of determinations per program. Free form text CMS checks to ensure sample size proportionately distributed


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sample Timeframe Distribution Describe the timeframes from which the sample will be drawn. Specify the number of cases sampled from each selected timeframe. 1st round pilot (due June 2014): Sample determinations made October 2013 – March 2014. Sample size must be equally split between October – December 2013 determinations and January – March 2014 determinations Free form text CMS checks to ensure timeframes within specified parameters and equal representation between first and second quarters


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Method for drawing sample Describe sampling methodology Free form text CMS checks to ensure sample is random


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Review Review Process Describe review process. Specify how errors will be identified and the robustness of review completed. Explain steps taken by reviewers to determine errors. Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Payment Review Specify how the state will identify improper payments associated with active case errors. Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































QC Procedures for Review Describe the quality control procedures for ensuring accuracy of the review decision that will reported in the pilot results (i.e. re-review of 10% of sampled cases) Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Test Cases Test Case Information Describe the frequency and timing of running test cases. Include any other comments the state sees fit to share regarding test cases. Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Results For each field below specify how the proposed pilot will enable the state to report on each measure.





















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Was the decision about program eligibility correct? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Was the decision about eligibility group correct? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































If the decision has been finalized and denied, was the case transferred to the SBM/FFM appropriately? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































If the decision has been finalized and denied, have appropriate notices been sent? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































If the application was transferred from a SBM/FFM, were appropriate steps taken to ensure reuse of information? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Were the appropriate attestations or verifications made for data collected in the application as identified in the state’s verification plan before disposition? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































If additional information was sought from the applicant or beneficiary, was such information properly requested based on attestation and verifications, or existing data, and utilized properly in the eligibility determination? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Based on the information supplied, attested and verified, was the household composition and income level for the applicant properly established?
 Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Based on the information supplied, attested and verified, was the citizenship and immigration status for the applicant properly established? Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Performance of automated processes and analysis on the results of the test cases. Describe how state will report on this measure Free form text CMS checks for reasonableness


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Analysis by point of application/type of application/channel Describe how proposed pilot will enable state to report on this measure Free form text CMS checks for reasonableness and that analysis meets requirements specified in pilot parameters


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Other factors Other factors the states will report results on; state can specify that there are none Free form text CMS checks for completion


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Other Comments (optional) Any comments the state would like to enter Free form text No review











































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































PRA Disclosure Statement













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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1148.  The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































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