Information Collection

Collection #15 Medicaid State Plan Eligibility

IC 207375 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 Collection #15 Medicaid State Plan Eligibility	Form
CMS-10398 A1-A3 A1-A3.pdf	Form
CMS-10398 S10 S10.pdf	Form
CMS-10398 S14 S14.pdf	Form
CMS-10398 S21 S21.pdf	Form
CMS-10398 S25 S25.pdf	Form
CMS-10398 S28 S28.pdf	Form
CMS-10398 S30 S30.pdf	Form
CMS-10398 S32 S32.pdf	Form
CMS-10398 S33 S33.pdf	Form
CMS-10398 S50 S50.pdf	Form
CMS-10398 S51 S51.pdf	Form
CMS-10398 S52 S52.pdf	Form
CMS-10398 S53 S53.pdf	Form
CMS-10398 S54 S54.pdf	Form
CMS-10398 S55 S55.pdf	Form
CMS-10398 S57 S57.pdf	Form
CMS-10398 S59 S59.pdf	Form
CMS-10398 S88 S88.pdf	Form
CMS-10398 S89 S89.pdf	Form
CMS-10398 S94 S94.pdf	Form
Medicaid State Plan Eligibility Supporting Statement [rev 6-14-2013].docx Supporting Statement	IC Document

IC Title:

Collection #15 Medicaid State Plan Eligibility

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398	A1-A3	A1-A3.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S10	S10.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S14	S14.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S21	S21.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S25	S25.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S28	S28.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S30	S30.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S32	S32.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S33	S33.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S50	S50.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S51	S51.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S52	S52.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S53	S53.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S54	S54.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S55	S55.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S57	S57.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S59	S59.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S88	S88.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S89	S89.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398	S94	S94.pdf	Yes	Yes	Fillable Fileable

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	56	0	0	0	0	0
Annual IC Time Burden (Hours)	1,120	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Medicaid State Plan Eligibility Supporting Statement [rev 6-14-2013].docx	06/14/2013

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