Information Collection

GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility

IC 236741 under ICR 201708-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1 GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility	Form and Instruction
CMS-10434 #15 Designation and Authority QSSI-MACPro-PRA-A1.pdf	Form and Instruction
CMS-10434 #15 Intergovernmental Cooperation Act Waivers QSSI-MACPro-PRA-A2.pdf	Form and Instruction
CMS-10434 #15 Eligibility Determinations and Fair Hearings QSSI-MACPro-PRA-A3.pdf	Form and Instruction
CMS-10434 #15 Organization and Administration QSSI-MACPro-PRA-A4.pdf	Form and Instruction
1 Single State Agency Assurances QSSI-MACPro-PRA-A5.pdf	Form and Instruction
1 Submission Summary QSSI-MACPro-PRA-I1.pdf	Form and Instruction
1 Medicaid State Plan QSSI-MACPro-PRA-I2.pdf	Form and Instruction
1 Public Comment QSSI-MACPro-PRA-I3.pdf	Form and Instruction
1 Tribal Input QSSI-MACPro-PRA-I4.pdf	Form and Instruction
1 Other Comment QSSI-MACPro-PRA-I5.pdf	Form and Instruction
1 MAGI Based Methodologies QSSI-MACPro-PRA-S10.pdf	Form and Instruction
1 MAGI Based Methodologies – Territories QSSI-MACPro-PRA-S10T.pdf	Form and Instruction
1 Reasonable Classification of Children All QSSI-MACPro-PRA-S11.pdf	Form and Instruction
1 Reasonable Classification of Children Limit QSSI-MACPro-PRA-S11a.pdf	Form and Instruction
1 Income Standard QSSI-MACPro-PRA-S13a.pdf	Form and Instruction
1 AFDC Income Standards QSSI-MACPro-PRA-S14.pdf	Form and Instruction
1 Income Standards – Poverty Level – Territories QSSI-MACPro-PRA-S14a.pdf	Form and Instruction
1 Income Standards - AFDC-related – Territories QSSI-MACPro-PRA-S14T.pdf	Form and Instruction
1 Presumptive Eligibility for Children under Age 19 QSSI-MACPro-PRA-S16.pdf	Form and Instruction
1 Qualified Entities QSSI-MACPro-PRA-S17.pdf	Form and Instruction
1 Financial Eligibility Requirements for Non-MAGI Groups QSSI-MACPro-PRA-S2.pdf	Form and Instruction
1 Presumptive Eligibility by Hospitals QSSI-MACPro-PRA-S21.pdf	Form and Instruction
1 Parents and Other Caretaker Relatives QSSI-MACPro-PRA-S25.pdf	Form and Instruction
1 Presumptive Eligibility for Parents and Other Caretaker QSSI-MACPro-PRA-S25a.pdf	Form and Instruction
1 Pregnant Women QSSI-MACPro-PRA-S28.pdf	Form and Instruction
1 Presumptive Eligibility for Pregnant Women QSSI-MACPro-PRA-S28a.pdf	Form and Instruction
1 Presumptive Eligibility for Pregnant Women QSSI-MACPro-PRA-S28T.pdf	Form and Instruction
1 Financial Eligibility Requirements for Non-MAGI Groups – QSSI-MACPro-PRA-S2T.pdf	Form and Instruction
1 Optional Eligibility Groups QSSI-MACPro-PRA-S3.pdf	Form and Instruction
1 Infants and Children under Age 19 QSSI-MACPro-PRA-S30.pdf	Form and Instruction
1 Infants and Children under Age 19 – Territories QSSI-MACPro-PRA-S30T.pdf	Form and Instruction
1 Adult Group QSSI-MACPro-PRA-S32.pdf	Form and Instruction
1 Adult Group - Presumptive Eligibility QSSI-MACPro-PRA-S32a.pdf	Form and Instruction
1 Adult Group - Presumptive Eligibility – Territories QSSI-MACPro-PRA-S32T.pdf	Form and Instruction
1 Former Foster Care Children QSSI-MACPro-PRA-S33.pdf	Form and Instruction
1 Former Foster Care Children – Presumptive Eligibility QSSI-MACPro-PRA-S33a.pdf	Form and Instruction
1 De-selected QSSI-MACPro-PRA-S3a.pdf	Form and Instruction
1 Mandatory Eligibility Groups QSSI-MACPro-PRA-S4.pdf	Form and Instruction
1 Individuals above 133% FPL under Age 65 QSSI-MACPro-PRA-S50.pdf	Form and Instruction
1 Individuals above 133% FPL under Age 65 - Presumptive El QSSI-MACPro-PRA-S50a.pdf	Form and Instruction
1 Optional Coverage of Parents and Other Caretaker Relativ QSSI-MACPro-PRA-S51.pdf	Form and Instruction
1 Reasonable Classification of Individuals under Age 21 QSSI-MACPro-PRA-S52.pdf	Form and Instruction
1 Children with Non IV-E Adoption Assistance QSSI-MACPro-PRA-S53.pdf	Form and Instruction
1 Optional Targeted Low Income Children QSSI-MACPro-PRA-S54.pdf	Form and Instruction
1 Individuals with Tuberculosis QSSI-MACPro-PRA-S55.pdf	Form and Instruction
1 Independent Foster Care Adolescents QSSI-MACPro-PRA-S57.pdf	Form and Instruction
1 Individuals Eligible for Family Planning Services QSSI-MACPro-PRA-S59.pdf	Form and Instruction
1 Individuals Eligible for Family Planning Services - Pres QSSI-MACPro-PRA-S59a.pdf	Form and Instruction
1 State Residency QSSI-MACPro-PRA-S88.pdf	Form and Instruction
1 Citizenship and Non-Citizenship QSSI-MACPro-PRA-S89.pdf	Form and Instruction
1 Eligibility Process QSSI-MACPro-PRA-S94.pdf	Form and Instruction
1 Application QSSI-MACPro-PRA-S94a.pdf	Form and Instruction
GenIC 15 - Supporting Statement (rev 06-28-2019 by OSORA PRA).docx Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility

Agency IC Tracking Number:

CMCS

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 and Instruction	1	Tribal Input	QSSI-MACPro-PRA-I4.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	AFDC Income Standards	QSSI-MACPro-PRA-S14.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Income Standards â Poverty Level â Territories	QSSI-MACPro-PRA-S14a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Income Standards - AFDC-related â Territories	QSSI-MACPro-PRA-S14T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Presumptive Eligibility for Children under Age 19	QSSI-MACPro-PRA-S16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Qualified Entities	QSSI-MACPro-PRA-S17.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Financial Eligibility Requirements for Non-MAGI Groups	QSSI-MACPro-PRA-S2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Presumptive Eligibility by Hospitals	QSSI-MACPro-PRA-S21.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Other Comment	QSSI-MACPro-PRA-I5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	MAGI Based Methodologies	QSSI-MACPro-PRA-S10.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	MAGI Based Methodologies â Territories	QSSI-MACPro-PRA-S10T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Reasonable Classification of Children All	QSSI-MACPro-PRA-S11.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Reasonable Classification of Children Limit	QSSI-MACPro-PRA-S11a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Income Standard	QSSI-MACPro-PRA-S13a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Parents and Other Caretaker Relatives	QSSI-MACPro-PRA-S25.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Presumptive Eligibility for Parents and Other Caretaker Relatives	QSSI-MACPro-PRA-S25a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10434 #15	Designation and Authority	QSSI-MACPro-PRA-A1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10434 #15	Intergovernmental Cooperation Act Waivers	QSSI-MACPro-PRA-A2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10434 #15	Eligibility Determinations and Fair Hearings	QSSI-MACPro-PRA-A3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10434 #15	Organization and Administration	QSSI-MACPro-PRA-A4.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Single State Agency Assurances	QSSI-MACPro-PRA-A5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Submission Summary	QSSI-MACPro-PRA-I1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Medicaid State Plan	QSSI-MACPro-PRA-I2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Public Comment	QSSI-MACPro-PRA-I3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Pregnant Women	QSSI-MACPro-PRA-S28.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Presumptive Eligibility for Pregnant Women	QSSI-MACPro-PRA-S28a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Presumptive Eligibility for Pregnant Women	QSSI-MACPro-PRA-S28T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Financial Eligibility Requirements for Non-MAGI Groups â Territories	QSSI-MACPro-PRA-S2T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Optional Eligibility Groups	QSSI-MACPro-PRA-S3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Infants and Children under Age 19	QSSI-MACPro-PRA-S30.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Infants and Children under Age 19 â Territories	QSSI-MACPro-PRA-S30T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Adult Group	QSSI-MACPro-PRA-S32.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Adult Group - Presumptive Eligibility	QSSI-MACPro-PRA-S32a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Adult Group - Presumptive Eligibility â Territories	QSSI-MACPro-PRA-S32T.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Former Foster Care Children	QSSI-MACPro-PRA-S33.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Former Foster Care Children â Presumptive Eligibility	QSSI-MACPro-PRA-S33a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	De-selected	QSSI-MACPro-PRA-S3a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Mandatory Eligibility Groups	QSSI-MACPro-PRA-S4.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Individuals above 133% FPL under Age 65	QSSI-MACPro-PRA-S50.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Individuals above 133% FPL under Age 65 - Presumptive Eligibility	QSSI-MACPro-PRA-S50a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Optional Coverage of Parents and Other Caretaker Relatives	QSSI-MACPro-PRA-S51.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Reasonable Classification of Individuals under Age 21	QSSI-MACPro-PRA-S52.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Children with Non IV-E Adoption Assistance	QSSI-MACPro-PRA-S53.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Optional Targeted Low Income Children	QSSI-MACPro-PRA-S54.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Individuals with Tuberculosis	QSSI-MACPro-PRA-S55.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Independent Foster Care Adolescents	QSSI-MACPro-PRA-S57.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Individuals Eligible for Family Planning Services	QSSI-MACPro-PRA-S59.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Individuals Eligible for Family Planning Services - Presumptive Eligibility	QSSI-MACPro-PRA-S59a.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	State Residency	QSSI-MACPro-PRA-S88.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Citizenship and Non-Citizenship	QSSI-MACPro-PRA-S89.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Eligibility Process	QSSI-MACPro-PRA-S94.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Application	QSSI-MACPro-PRA-S94a.pdf	Yes	Yes	Fillable Fileable

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	GenIC 15 - Supporting Statement (rev 06-28-2019 by OSORA PRA).docx	06/28/2019

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