Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)

Documents and Forms

Document Name Document Type
Form CMS-10300 Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300) Form and Instruction
CMS-10300 Additional State Plan Option for Providing Premium Assis CMS-10300 XXI Template1 revised 3-4-10.doc Form and Instruction
CMS-10300 Additional State Plan Option for Providing Premium Assis CMS-10300 XIX Template2 revised 3-4-10 per OMB.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10300	Additional State Plan Option for Providing Premium Assistance CHIP Mediciad Template	CMS-10300 XIX Template2 revised 3-4-10 per OMB.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10300	Additional State Plan Option for Providing Premium Assistance CHIP SPA Template	CMS-10300 XXI Template1 revised 3-4-10.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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