Information Collection

#15: Medicaid State Plan Eligibility

IC 214314 under ICR 201410-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (#15) #15: Medicaid State Plan Eligibility	Form
CMS-10398 (#15) Medicaid Administration: State Plan Administration/ Desi A1-A3.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: MAGI-Based Income Methodologies S10.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: AFDC Income Standards S14.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Presumptive Eligibility by Hospita S21.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Parents and Oth S25.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Pregnant Women S28.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Infants and Chi S30.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Adult Group S32.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Former Foster C S33.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals a S50.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Cove S51.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Reasonable Cl S52.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Children with S53.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Targ S54.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals w S55.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Independent F S57.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals E S59.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility State Re S88.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility Citizens S89.pdf	Form
CMS-10398 (#15) Medicaid Eligibility: General Eligibility Requirements E S94.pdf	Form
#15 Medicaid State Plan Eligibility Supporting Statement [Dec 2014].docx #15 Supporting Statement: Medicaid State Plan Eligibility	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

#15: Medicaid State Plan Eligibility

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 (#15)	Medicaid Eligibility: Options for Coverage Individuals above 133% FPL	S50.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21	S52.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance	S53.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children	S54.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility	S89.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: General Eligibility Requirements Eligibility Process	S94.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Administration: State Plan Administration/ Designation and Authority	A1-A3.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: MAGI-Based Income Methodologies	S10.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: AFDC Income Standards	S14.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Presumptive Eligibility by Hospitals	S21.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives	S25.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Mandatory Coverage Pregnant Women	S28.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19	S30.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Mandatory Coverage Adult Group	S32.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Mandatory Coverage Former Foster Care Children	S33.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives	S51.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis	S55.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents	S57.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services	S59.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#15)	Medicaid Eligibility: Non-Financial Eligibility State Residency	S88.pdf	Yes	Yes	Fillable Printable

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
	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

table that charts IC Documents
Title	Document	Date Uploaded
#15 Supporting Statement: Medicaid State Plan Eligibility	#15 Medicaid State Plan Eligibility 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.