Information Collection

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

IC 229612 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

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	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 â Medicaid Eligibility: MAGI-Based Income Methodologies	S10.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S14 â Medicaid Eligibility: AFDC Income Standards	S14.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S21 â Medicaid Eligibility: Presumptive Eligibility by Hospitals	S21.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S25 â Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives	S25.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S28 â Medicaid Eligibility: Mandatory Coverage Pregnant Women	S28.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S30 â Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19	S30.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S32 â Medicaid Eligibility: Mandatory Coverage Adult Group	S32.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S33 â Medicaid Eligibility: Mandatory Coverage Former Foster Care Children	S33.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S50 â Medicaid Eligibility: Options for Coverage Individuals above 133% FPL	S50.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S51 â 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 â 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 â 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 â Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children	S54.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S55 â Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis	S55.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S57 â Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents	S57.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S59 â 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 â Medicaid Eligibility: Non-Financial Eligibility State Residency	S88.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S94 â Medicaid Eligibility: General Eligibility Requirements Eligibility Process	S94.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #15	Tab S89 â 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 %

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

Documents for IC

table that charts IC Documents
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.