CHIP Templates Supporting Statement OPTIMIZED

Application to Use Burden/Hours from Generic PRA Clearance:
Medicaid and CHIP State Plan, Waiver, and Program Submissions
(CMS-10398, OMB 0938-1148)
Information Collection #17 CHIP State Plan Eligibility

June 25, 2013

Center for Medicaid and CHIP Services (CMCS)
Centers for Medicare & Medicaid Services (CMS)

A. Background
The Centers for Medicare & Medicaid Services (CMS) work in partnership with States to
implement Medicaid and the Children’s Health Insurance Program (CHIP). Together these
programs provide health coverage to millions of Americans. Medicaid and CHIP are based in
Federal statute, associated regulations and policy guidance, and the approved State plan
documents that serve as a contract between CMS and States about how Medicaid and CHIP will
be operated in that State. CMS works collaboratively with States in the ongoing management of
programs and policies, and CMS continues to develop implementing guidance and templates for
States to use to elect new options available as a result of the Affordable Care Act or to comply
with new statutory provisions. CMS also continues to work with States through other methods to
further the goals of health reform, including program waivers and demonstrations, and other
technical assistance initiatives.
B. Description of Information Collection
Medicaid, authorized by Title XIX of the Social Security Act, and CHIP, reauthorized by the
Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) signed into law on
February 4, 2009, play an important role in financing health care for approximately 48 million
people throughout the country. By 2014, it is expected that an additional 16 million people will
become eligible for Medicaid and CHIP as a result of the Affordable Care Act (Public Law 111148 – Patient Protection and Affordable Care Act). In order to implement the statute, CMS must
provide a mechanism to ensure timely approval of Medicaid and CHIP State plans, waivers and
demonstrations and provide a repository for all Medicaid and CHIP program data that supplies
data to populate Healthcare.gov (sec. 1103) as well as other required reports. With these
statutory changes in the Medicaid and CHIP programs, CMS will undergo a transformation from
a reactive, mostly paper based processing entity to an active, electronic based program manager
by automating and streamlining the current systems and processes.
Additionally, 42 CFR 430.12 sets forth the authority for the submittal and collection of State
plans and plan amendment information in a format defined by CMS. A State plan for Medicaid
consists of preprinted material that covers the basic requirements, and individualized content that
reflects the characteristics of the particular State's program. Pursuant to this requirement, CMS
has created the MACPro system. This system will be used by CMS and State Medicaid
agencies. Overall, MACPro will be used by both State and CMS officials to improve the State
application and Federal review processes, improve Federal program management of Medicaid
programs and CHIP, and standardize Medicaid program data. Specifically, it will be used by
State agencies to (among other things):
• Submit and amend Medicaid State Plans, CHIP State Plans and Information System,
Advanced Planning Documents (APDs);
• Submit applications and amendments for State waivers, demonstration, and
benchmark and grant programs.
In addition, it will be used by CMS to (among other things):
• Provide for the review and disposition of applications and
• Monitor and track application activity.
CMS is releasing Adobe pdfs (PDFs) that reflect the screens that were developed for the
MACPro system. States will fill out these forms electronically in the same manner they will

eventually fill them out in the MACPro system. States will then submit them via a web portal to
an existing CMS vehicle, the Medicaid Model Data Lab (MMDL). In this manner, we will begin
the process of engaging states electronically for the purpose of changing Medicaid or CHIP
programs. The level of effort to fill out these forms remains the same as will be necessary with
the full MACPro system, as does the level of effort to submit the forms. The PDF interim
process will be used for both the Medicaid Alternative Benefit Plans (ABPs), and CHIP
eligibility templates that have received PRA approval as part of the MACPro system.

C. Deviations from Generic Request
No deviations are requested.
D. Burden Hour Deduction
The total approved burden ceiling of the generic ICR is 86,240 hours, and CMS previously
requested to use 27,108 hours, leaving our burden ceiling at 59,132 hours. CMS estimates that
each State will complete the collection of data and submission to CMS within 50 hours. There is
a potential universe of 56 respondents, so the total burden deducted from the total for this request
is 2,800 hours.
E. Timeline
CMS hopes to deploy this collection in July 2013.
The following attachments are provided for this information collection:
 CS3 - Eligibility for Medicaid Expansion Program
 CS7 - Eligibility - Targeted Low-Income Children
 CS8 - Eligibility - Targeted Low-Income Pregnant Women
 CS9 - Eligibility - Coverage From Conception to Birth
 CS10 - Eligibility - Children Who Have Access to Public Employee Coverage
 CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
 CS12 - Eligibility - Dental Only Supplemental Coverage
 CS13 - Eligibility - Deemed Newborns
 CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income
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Disregards
CS15 - MAGI-Based Income Methodologies
CS16 - Other Eligibility Criteria - Spenddowns
CS17 - Non-Financial Eligibility – Residency
CS18 - Non-Financial Eligibility – Citizenship
CS19 - Non-Financial Eligibility - Social Security Number
CS20 - Non-Financial Eligibility - Substitution of Coverage

CS21 - Non-Financial Eligibility - Non-Payment of Premiums
CS23 - Non-Financial Requirements - Other Eligibility Standards
CS24 - General Eligibility - Eligibility Processing
CS27 - Non-Financial Requirements - Other Eligibility Standards

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CS28 - General Eligibility - Presumptive Eligibility for Children
CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women