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GenIC #2 - CHIP State Plan Eligibility

IC 220809 under ICR 201603-0938-022 · OMB 0938-1188.

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GenIC #2 - CHIP State Plan Eligibility
 
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-10434 (#2) CHIP Admin GenIC #2 Screen Shots - CHIP Admin.pdf Yes Yes Fillable Printable
Form CMS-10434 (#2) CHIP Eligibility GenIC #2 Screen Shots - CHIP Eligibility.pdf Yes Yes Fillable Printable
Instruction #2 - IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx No   Printable Only
Instruction #2 - IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx Yes Yes Printable Only
Instruction #2 - IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx Yes Yes Printable Only
Instruction #2 - IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx Yes Yes Printable Only
Instruction #2 - IG_CHIP Admin Introduction_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx No   Printable Only
Instruction #2 - IG_CS6 - Income Standards_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx No   Printable Only
Instruction #2 - IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx No   Printable Only
Instruction #2 - IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS16 - Spenddown_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx No   Printable Only
Instruction #2 - IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx No   Printable Only

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) 1,568 0 1,568 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
GenIC #2 - Supporting Statement (CHIP State Plan Eligibility) GenIC # 2 - Supporting Statement CHIP Templates [rev 03-28-2016 by OSORA PRA].docx 03/30/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.