Information Collection

Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care

IC 43679 under ICR 200711-0938-005 · OMB 0938-0994.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0994 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10178 Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care	Form and Instruction
CMS-10178 CAP SHO Letter CAP SHO Letter FINAL to OMB 090407.doc	Form and Instruction

IC Title:

Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10178	CAP SHO Letter	CAP SHO Letter FINAL to OMB 090407.doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	23,400	23,400
Annual IC Time Burden (Hours)	23,400	23,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.