#14: MAGI Conversion Plan

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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 (#14) #14: MAGI Conversion Plan Form and Instruction
CMS-10398 (#14) Modified Adjusted Gross Income (MAGI) Conversion Plan MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx Form and Instruction
#14 MAGI Conversion Plan Supporting Statement [Dec 2014].docx #14 Supporting Statement: MAGI Conversion Plan IC Document

Information Collection (IC) Details

IC Title:	#14: MAGI Conversion Plan	Agency IC Tracking Number:

IC Status: New

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 and Instruction	CMS-10398 (#14)	Modified Adjusted Gross Income (MAGI) Conversion Plan	MAGI Income Conversion Plan revised_4_3 [rev 4-5-13 by OSORA PRA].docx		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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#14 Supporting Statement: MAGI Conversion Plan	#14 MAGI Conversion Plan Supporting Statement [Dec 2014].docx	12/22/2014

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