Document Name Document Type
Form CMS-10398 #15 GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility Form and Instruction
CMS-10398 #15 Tab A1-A3 - Medicaid Administration: State Plan Administ A1-A3 (1).pdf Form and Instruction
CMS-10398 #15 Tab S10 – Medicaid Eligibility: MAGI-Based Income Method S10.pdf Form and Instruction
CMS-10398 #15 Tab S14 – Medicaid Eligibility: AFDC Income Standards S14.pdf Form and Instruction
CMS-10398 #15 Tab S21 – Medicaid Eligibility: Presumptive Eligibility S21.pdf Form and Instruction
CMS-10398 #15 Tab S25 – Medicaid Eligibility: Mandatory Coverage Paren S25.pdf Form and Instruction
CMS-10398 #15 Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregn S28.pdf Form and Instruction
CMS-10398 #15 Tab S30 – Medicaid Eligibility: Mandatory Coverage Infan S30.pdf Form and Instruction
CMS-10398 #15 Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult S32.pdf Form and Instruction
CMS-10398 #15 Tab S33 – Medicaid Eligibility: Mandatory Coverage Forme S33.pdf Form and Instruction
CMS-10398 #15 Tab S50 – Medicaid Eligibility: Options for Coverage Ind S50.pdf Form and Instruction
CMS-10398 #15 Tab S51 – Medicaid Eligibility: Options for Coverage Opt S51.pdf Form and Instruction
CMS-10398 #15 Tab S52 – Medicaid Eligibility: Options for Coverage Rea S52.pdf Form and Instruction
CMS-10398 #15 Tab S53 – Medicaid Eligibility: Options for Coverage Chi S53.pdf Form and Instruction
CMS-10398 #15 Tab S54 – Medicaid Eligibility: Options for Coverage Opt S54.pdf Form and Instruction
CMS-10398 #15 Tab S55 – Medicaid Eligibility: Options for Coverage Ind S55.pdf Form and Instruction
CMS-10398 #15 Tab S57 – Medicaid Eligibility: Options for Coverage Ind S57.pdf Form and Instruction
CMS-10398 #15 Tab S59 – Medicaid Eligibility: Options for Coverage Ind S59.pdf Form and Instruction
CMS-10398 #15 Tab S88 – Medicaid Eligibility: Non-Financial Eligibilit S88.pdf Form and Instruction
CMS-10398 #15 Tab S89 – Medicaid Eligibility: Non-Financial Eligibilit S89.pdf Form and Instruction
CMS-10398 #15 Tab S94 – Medicaid Eligibility: General Eligibility Requ S94.pdf Form and Instruction
15 - Final Supporting Statement Medicaid State Plan Eligibility.docx #15 - Supporting Statement IC Document

Information Collection (IC) Details

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IC Title:	GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #15	Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority	A1-A3 (1).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies	S10.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S14 – Medicaid Eligibility: AFDC Income Standards	S14.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals	S21.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives	S25.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women	S28.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19	S30.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group	S32.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children	S33.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL	S50.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives	S51.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21	S52.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance	S53.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children	S54.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis	S55.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents	S57.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services	S59.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency	S88.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process	S94.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility	S89.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 %

	Requested	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

Title	Document	Date Uploaded
#15 - Supporting Statement	15 - Final Supporting Statement Medicaid State Plan Eligibility.docx	12/29/2017

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

GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

OMB: 0938-1148

IC ID: 229612

View Information Collection (IC)