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

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