MAGI Conversion Plan Part 2 (GenIC #27)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10398 (#27) MAGI Conversion Plan Part 2 (GenIC #27) Form and Instruction
CMS-10398 (#27) Part 2 of Modified Adjusted Gross Income (MAGI) Conversi Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.doc Form and Instruction
MAGI Conversion Plan II Supporting Statement.docx Supporting Statement - MAGI Conversion Plan Part 2 IC Document

Information Collection (IC) Details

IC Title:	MAGI Conversion Plan Part 2 (GenIC #27)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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-10398 (#27)	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan	Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.doc		Yes	Yes	Fillable Printable

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 %

	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

Title	Document	Date Uploaded
Supporting Statement - MAGI Conversion Plan Part 2	MAGI Conversion Plan II Supporting Statement.docx	11/19/2013

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