GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews

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⚠️ Notice: This information collection may be referencing outdated material.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
ModelEligibilityResultsPage_Scens 5+8a_v11rc_060316.pdf Other-Model Online Eligibility Resul
CMS-10398 #49 Testing Protocol CMS_ModelOnlineEligibilityResultsPage_Protocol_061016.docx Form and Instruction
GenIC #49 - Eligibility Results, Consumer Testing Interviews [rev 06-12-2016 by OSORA PRA].docx GenIC #49 - Model Online Eligibility Results: Consumer Testing Interviews IC Document

Information Collection (IC) Details

IC Title:	GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Online Eligibility Results Page			ModelEligibilityResultsPage_Scens 5+8a_v11rc_060316.pdf		Yes	No	Printable Only
Form and Instruction	CMS-10398 #49	Testing Protocol	CMS_ModelOnlineEligibilityResultsPage_Protocol_061016.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #49 - Model Online Eligibility Results: Consumer Testing Interviews	GenIC #49 - Eligibility Results, Consumer Testing Interviews [rev 06-12-2016 by OSORA PRA].docx	06/12/2016

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