Information Collection

GenIC #17 (Extension w/o change): CHIP State Plan Eligibility

IC 229614 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⚠️ Notice: This information collection may be referencing outdated material.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 #17 GenIC #17 (Extension w/o change): CHIP State Plan Eligibility	Form
CMS-10398 #17 CS3 - Eligibility for Medicaid Expansion Program CS3.jpg	Form
CMS-10398 #17 CS8 - Eligibility - Targeted Low-Income Pregnant Women CS8.jpg	Form
CMS-10398 #17 CS9 - Eligibility - Coverage From Conception to Birth CS9.jpg	Form
CMS-10398 #17 CS10 - Eligibility - Children Who Have Access to Public CS10.pdf	Form
CMS-10398 #17 CS11 - Eligibility - Pregnant Women Who Have Access to P CS11.pdf	Form
CMS-10398 #17 CS12 - Eligibility - Dental Only Supplemental Coverage CS12.pdf	Form
CMS-10398 #17 CS13 - Eligibility - Deemed Newborns CS13.jpg	Form
CMS-10398 #17 CS14 - Eligibility - Children Ineligible for Medicaid as CS14.pdf	Form
CMS-10398 #15 CS15 - MAGI-Based Income Methodologies CS15.pdf	Form
CMS-10398 #17 CS16 - Other Eligibility Criteria - Spenddowns CS16.pdf	Form
CMS-10398 #17 CS17 - Non-Financial Eligibility – Residency CS17.pdf	Form
CMS-10398 #17 CS19 - Non-Financial Eligibility - Social Security Numbe CS19.pdf	Form
CMS-10398 #17 CS20 - Non-Financial Eligibility - Substitution of Cover CS20.pdf	Form
CMS-10398 #17 CS21 - Non-Financial Eligibility - Non-Payment of Premiu CS21.pdf	Form
CMS-10398 #17 CS23 - Non-Financial Requirements - Other Eligibility St CS23.pdf	Form
CMS-10398 #17 CS24 - General Eligibility - Eligibility Processing CS24.pdf	Form
CMS-10398 #17 CS27 - Non-Financial Requirements - Other Eligibility St CS27.pdf	Form
CMS-10398 #17 CS28 - General Eligibility - Presumptive Eligibility for CS28.pdf	Form
CMS-10398 #17 CS29 - General Eligibility - Presumptive Eligibility for CS29.pdf	Form
CMS-10398 #17 CS7 - Eligibility - Targeted Low-Income Children IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx	Form
17 - Final Supporting Statement CHIP State Plan Eligibility.docx #17 - Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #17 (Extension w/o change): CHIP 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	CMS-10398 #17	CS3 - Eligibility for Medicaid Expansion Program	CS3.jpg	No		Fillable Fileable
Form	CMS-10398 #17	CS8 - Eligibility - Targeted Low-Income Pregnant Women	CS8.jpg	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS9 - Eligibility - Coverage From Conception to Birth	CS9.jpg	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS10 - Eligibility - Children Who Have Access to Public Employee Coverage	CS10.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS11 - Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	CS11.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS12 - Eligibility - Dental Only Supplemental Coverage	CS12.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS13 - Eligibility - Deemed Newborns	CS13.jpg	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS14 - Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	CS14.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #15	CS15 - MAGI-Based Income Methodologies	CS15.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS16 - Other Eligibility Criteria - Spenddowns	CS16.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS17 - Non-Financial Eligibility â Residency	CS17.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS19 - Non-Financial Eligibility - Social Security Number	CS19.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS20 - Non-Financial Eligibility - Substitution of Coverage	CS20.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS21 - Non-Financial Eligibility - Non-Payment of Premiums	CS21.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS23 - Non-Financial Requirements - Other Eligibility Standards	CS23.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS24 - General Eligibility - Eligibility Processing	CS24.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS27 - Non-Financial Requirements - Other Eligibility Standards	CS27.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS28 - General Eligibility - Presumptive Eligibility for Children	CS28.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS29 - General Eligibility - Presumptive Eligibility for Pregnant Women	CS29.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	CS7 - Eligibility - Targeted Low-Income Children	IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx	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)	2,800	2,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#17 - Supporting Statement	17 - Final Supporting Statement CHIP 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.