#17 CHIP State Plan Eligibility (MACPro Templates)

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

OMB: 0938-1148

IC ID: 214318

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#17 CHIP State Plan Eligibility (MACPro Templates)
 
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 CMS-10398 (#17) Template CS7 – Targeted Low-Income Child IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx Yes Yes Printable Only
Form CMS-10398 (#17) Eligibility for Medicaid Expansion Program CS3.jpg Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Targeted Low-Income Pregnant Women CS8.jpg Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Deemed Newborns CS13.jpg Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Coverage From Conception to Birth CS9.jpg Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Eligibility – Citizenship CS18.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Eligibility - Social Security Number CS19.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) General Eligibility - Eligibility Processing CS24.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Children Who Have Access to Public Employee Coverage CS10.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Pregnant Women Who Have Access to Public Employee Coverage CS11.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Dental Only Supplemental Coverage CS12.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Other Eligibility Criteria - Spenddowns CS16.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Eligibility - Substitution of Coverage CS20.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards CS27.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Children CS28.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) MAGI-Based Income Methodologies CS15.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Eligibility – Residency CS17.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) Non-Financial Requirements - Other Eligibility Standards CS23.pdf Yes Yes Fillable Printable
Form CMS-10398 (#17) General Eligibility - Presumptive Eligibility for Pregnant Women CS29.pdf 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) 2,800 0 2,800 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#17 Supporting Statement: CHIP State Plan Eligibility (MACPro Templates) #17 CHIP Templates Supporting Statement OPTIMIZED [Dec 2014].doc 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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