Information Collection

CHIP Administration & Eligibility

IC 205311 under ICR 201301-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 CHIP Administration & Eligibility	Form and Instruction
IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx	Instruction
IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx	Instruction
IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx	Instruction
IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx	Instruction
IG_CHIP Admin Introduction_R1_Final_11-30-12.docx	Instruction
IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx	Instruction
IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx	Instruction
IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx	Instruction
IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx	Instruction
IG_CS6 - Income Standards_R1_Final_11-30-12.docx	Instruction
IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx	Instruction
IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx	Instruction
IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx	Instruction
IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Instruction
IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Instruction
IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx	Instruction
IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx	Instruction
IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx	Instruction
IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx	Instruction
IG_CS16 - Spenddown_R1_Final_11-30-12.docx	Instruction
IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx	Instruction
IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx	Instruction
IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx	Instruction
IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx	Instruction
IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx	Instruction
IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx	Instruction
IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx	Instruction
IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx	Instruction
IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx	Instruction
IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx	Instruction
IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx	Instruction
IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx	Instruction
IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx	Instruction
IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx	Instruction
IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx	Instruction
IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx	Instruction
IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx	Instruction
CMS-10434 CHIP Administration CHIP Admin Form.pdf	Form and Instruction
CMS-10434 CHIP Eligibility CHIP Eligibility Form.pdf	Form and Instruction
CHIP Admin Webinar Transcript.pdf CHIP Administration - Webinar Transcript	IC Document
CHIP Eligibility Transcript.pdf CHIP Eligibility - Webinar Transcript	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

CHIP Administration & Eligibility

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 430.12

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 and Instruction	CMS-10434	CHIP Administration	CHIP Admin Form.pdf	Yes	Yes	Fillable Fileable
Instruction			IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CHIP Admin Introduction_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx	Yes	No	Printable Only
Instruction			IG_CS6 - Income Standards_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS16 - Spenddown_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx	Yes	No	Printable Only
Form and Instruction	CMS-10434	CHIP Eligibility	CHIP Eligibility Form.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,568	1,568
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CHIP Administration - Webinar Transcript	CHIP Admin Webinar Transcript.pdf	01/08/2013
CHIP Eligibility - Webinar Transcript	CHIP Eligibility Transcript.pdf	01/09/2013

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