GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program

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⚠️ Notice: This information collection may be referencing outdated material.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 #34 GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program Form and Instruction
CMS-10398 #34 Template for Child Health Plan Under Title XXI of The So GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_CLEAN_07-03-2018.docx Form and Instruction
#34 - Generic Supporting Statement (rev 07-06-2018 by OSORA PRA) CLEAN.docx Supporting Statement IC Document
#34 - Crosswalk CHIP Managed Care Regs PRA_June 2018.xlsx Crosswalk: State Plan Template IC Document
GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_Track Changes_07-05-2018.docx Track Change: State Plan Template IC Document

Information Collection (IC) Details

IC Title:	GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Agency IC Tracking Number:	CMCS

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 and Instruction	CMS-10398 #34	Template for Child Health Plan Under Title XXI of The Social Security Act Children’s Health Insurance Program	GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_CLEAN_07-03-2018.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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	#34 - Generic Supporting Statement (rev 07-06-2018 by OSORA PRA) CLEAN.docx	07/06/2018
Crosswalk: State Plan Template	#34 - Crosswalk CHIP Managed Care Regs PRA_June 2018.xlsx	07/06/2018
Track Change: State Plan Template	GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_Track Changes_07-05-2018.docx	07/06/2018

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