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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.