Information Collection

GenIC #2 - CHIP State Plan Eligibility

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 (#2) GenIC #2 - CHIP State Plan Eligibility	Form
#2 - IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx	Instruction
#2 - IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx	Instruction
#2 - IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx	Instruction
#2 - IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CHIP Admin Introduction_R1_Final_11-30-12.docx	Instruction
#2 - IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx	Instruction
#2 - IG_CS6 - Income Standards_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx	Instruction
#2 - IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx	Instruction
#2 - IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS16 - Spenddown_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx	Instruction
#2 - IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx	Instruction
#2 - IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx	Instruction
CMS-10434 (#2) CHIP Admin GenIC #2 Screen Shots - CHIP Admin.pdf	Form
CMS-10434 (#2) CHIP Eligibility GenIC #2 Screen Shots - CHIP Eligibility.pdf	Form
GenIC # 2 - Supporting Statement CHIP Templates [rev 03-28-2016 by OSORA PRA].docx GenIC #2 - Supporting Statement (CHIP State Plan Eligibility)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #2 - CHIP State Plan Eligibility

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
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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	56	56
Annual IC Time Burden (Hours)	1,568	1,568
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.