Medicaid Enrollees and Disenrolles

CHIPRA_ Children Health Insurance

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0384 can be found here:

Documents and Forms

Document Name Document Type
0990-CHIP Part B_Attachment C_Pretest Report.pdf Other-survey
CHIP Part A_Attachment C2_Case Studies_Community Enrollment Agencies.pdf Other-study
CHIP Part A_Attachment C3_Case Studies_Health Care Providers.pdf Other-study
CHIP Part A_Attachment C1_Case Studies_State Officials.pdf Other-study
0990-CHIP Part A_Attachment C4_Case Studies_Managed Care and Health Plans.pdf Other-study

Information Collection (IC) Details

IC Title:	Medicaid Enrollees and Disenrolles	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-study	0990-CHIP Part A_Attachment C4_Case Studies_Managed Care and Health Plans.pdf	No	No	Paper Only
Other-survey	0990-CHIP Part B_Attachment C_Pretest Report.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C2_Case Studies_Community Enrollment Agencies.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C3_Case Studies_Health Care Providers.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C1_Case Studies_State Officials.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	2,250	2,250
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.