Information Collection

Medicaid Premiums and Cost Sharing (#29)

IC 210812 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⚠️ Notice: This information collection may be referencing outdated material.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 (#29) Medicaid Premiums and Cost Sharing (#29)	Form
IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Instruction
IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Instruction
IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Instruction
CMS-10398 (#29) Medicaid Premiums and Cost Sharing Copy of Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Form
CMS-R-53 - Generic Supporting Statement [rev 3-18-2014 by OSORA PRA].docx CMS-10398 (#29) Supporting Statement	IC Document
Cost Sharing Crosswalk 1 16 14 rys rb.pdf Crosswalk	IC Document
CMS R-53 Response to Comments to OMB (v2).doc Summary of Comments/CMS Response	IC Document
NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint.pdf NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint	IC Document
FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d.pdf FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d	IC Document

IC Title:

Medicaid Premiums and Cost Sharing (#29)

Agency IC Tracking Number:

IC Status: New

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#29)	Medicaid Premiums and Cost Sharing	Copy of Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Yes	Yes	Fillable Printable
Instruction			IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Yes	No	Printable Only
Instruction			IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Yes	No	Printable Only
Instruction			IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Yes	No	Printable Only
Instruction			IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Yes	No	Printable Only
Instruction			IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	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	10	0	0	0	0	0
Annual IC Time Burden (Hours)	50	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
CMS-10398 (#29) Supporting Statement	CMS-R-53 - Generic Supporting Statement [rev 3-18-2014 by OSORA PRA].docx	03/18/2014
Crosswalk	Cost Sharing Crosswalk 1 16 14 rys rb.pdf	03/18/2014
Summary of Comments/CMS Response	CMS R-53 Response to Comments to OMB (v2).doc	03/18/2014
NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint	NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint.pdf	03/18/2014
FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d	FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d.pdf	03/18/2014

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