GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators

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⚠️ Notice: This information collection may be referencing outdated material.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 #35 GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators Form
CMS-10398 #35 Eligibility and Enrollment Performance Indicators Templa GEN IC_35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx Form
35 - Supporting Statement Eligibility and Enrollment Performace.docx #35 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #35 (Extension w/o change): Eligibility and Enrollment Performance Indicators	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 #35	Eligibility and Enrollment Performance Indicators Template	GEN IC_35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	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	51	51
Annual IC Time Burden (Hours)	765	765
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#35 - Supporting Statement	35 - Supporting Statement Eligibility and Enrollment Performace.docx	01/11/2018

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