1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50

1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50 (CMS-10120)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0933 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10120 1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50 Form
CMS-10120 1932a SPA Preprint Official 1932 State Plan Preprint (2014 draft) -clean for PRA 10_18 10-30.pdf Form
Crosswalk of changes to 1932 SPA Preprint_final 508 approved.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10120	1932a SPA Preprint	Official 1932 State Plan Preprint (2014 draft) -clean for PRA 10_18 10-30.pdf		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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15	5	10
Annual IC Time Burden (Hours)	85	-15	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk of changes to 1932 SPA Preprint_final 508 approved.docx	02/25/2014

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