Information Collection

State Plan Template to Implement Section 6062 of the DRA (Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children) CMS-10232

IC 184270 under ICR 201105-0938-010 · OMB 0938-1045.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10232 FOA Preprint for PRA package- 2-16-11 _3_.pdf	Other-State Plan Preprint
CMS-10232 Draft FOA Preprint Crosswalk 2-16-11.pdf CMS-10232 Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State Plan Template to Implement Section 6062 of the DRA (Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children) CMS-10232

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Other-State Plan Preprint			CMS-10232 FOA Preprint for PRA package- 2-16-11 _3_.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10232 Crosswalk	CMS-10232 Draft FOA Preprint Crosswalk 2-16-11.pdf	05/23/2011

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