Information Collection

#29: Medicaid Cost Sharing (CMS-R-53)

IC 214342 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⚠️ Notice: This information collection may be referencing outdated material.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
IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Instruction
IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Instruction
IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Instruction
CMS-R-53 Medicaid Premiums and Cost Sharing Copy of Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Form
#29 Supporting Statement (CMS-R-53) [Dec 2014].docx #29 Supporting Statement: Medicaid Cost Sharing (CMS-R-53)	IC Document

IC Title:

#29: Medicaid Cost Sharing (CMS-R-53)

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
Instruction			IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Yes	Yes	Printable Only
Instruction			IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Printable Only
Instruction			IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Yes	Yes	Printable Only
Instruction			IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Printable Only
Instruction			IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Printable Only
Form	CMS-R-53	Medicaid Premiums and Cost Sharing	Copy of Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	10	10
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#29 Supporting Statement: Medicaid Cost Sharing (CMS-R-53)	#29 Supporting Statement (CMS-R-53) [Dec 2014].docx	12/22/2014

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