GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062)

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10398 #33 GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062) Form
CMS-10398 #33 FOA Preprint 33 - Preprint - DRA 6062 (_33) [rev 7-17-2014 by OSORA PRA].docx Form
33 - Revised Supporting Statement DRA 6062.docx #33 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #33 (Extension w/o change): Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children (DRA 6062)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #33	FOA Preprint	33 - Preprint - DRA 6062 (_33) [rev 7-17-2014 by OSORA PRA].docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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	40	40
Annual IC Time Burden (Hours)	3,200	3,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#33 - Supporting Statement	33 - Revised Supporting Statement DRA 6062.docx	01/09/2018

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