Information Collection

Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299)

IC 191979 under ICR 201002-0938-004 · OMB 0938-1082.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1082 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10299 Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299) Form and Instruction
CMS-10299 Draft CHIP State Plan for Section 214 Option Draft CHIP State Plan for Section 214 Option.doc Form and Instruction
CMS-10299 pre-print 5 year bar waiver CMS-10299 pre-print 5 year bar waiver.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299)	Agency IC Tracking Number:

Is this a Common Form?		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-10299	Draft CHIP State Plan for Section 214 Option	Draft CHIP State Plan for Section 214 Option.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10299	pre-print 5 year bar waiver	CMS-10299 pre-print 5 year bar waiver.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)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.