#14: MAGI Conversion Plan

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

OMB: 0938-1148

IC ID: 214301

Information Collection (IC) Details

View Information Collection (IC)

#14: MAGI Conversion Plan
 
New
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 56 0 0 0
Annual IC Time Burden (Hours) 1,120 0 1,120 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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