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

Medicaid and CHIP Program (MACPro) (CMS-10434)

OMB: 0938-1188

IC ID: 236741

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GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility CMCS
 
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 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 – Poverty Level – Territories QSSI-MACPro-PRA-S14a.pdf Yes Yes Fillable Fileable
Form and Instruction 1 Income Standards - AFDC-related – 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 – 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 – 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 – 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 – 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 – 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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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) 1,120 0 1,120 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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