Information Collection

GenIC #29 (Extension w/o change): Medicaid Cost Sharing

IC 229688 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⚠️ Notice: This information collection may be referencing outdated material.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
29 - IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Instruction
29 - IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
29 - IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Instruction
29 - IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Instruction
29 - IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Instruction
CMS-10398 #29 Medicaid Premiums and Cost Sharing 29 - Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Form
29 - Final Supporting Statement Medicaid Cost Sharing.docx #29 - Supporting Statement	IC Document

IC Title:

GenIC #29 (Extension w/o change): Medicaid Cost Sharing

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
Instruction			29 - IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Fillable Fileable
Instruction			29 - IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Fillable Fileable
Instruction			29 - IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf	Yes	Yes	Fillable Fileable
Instruction			29 - IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf	Yes	Yes	Fillable Fileable
Instruction			29 - IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #29	Medicaid Premiums and Cost Sharing	29 - Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	10	10
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#29 - Supporting Statement	29 - Final Supporting Statement Medicaid Cost Sharing.docx	01/09/2018

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