Information Collection

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

IC 43679 under ICR 200909-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	Medicaid and Children's Health Insurance Plan (CHIP) Managed Care	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 457.950

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	28,050	4,650	23,400
Annual IC Time Burden (Hours)	28,050	4,650	23,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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