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

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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:

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 %

	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
#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.

#15: Medicaid State Plan Eligibility

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

OMB: 0938-1148

IC ID: 214314

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