GenIC #34 (Revised): 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⚠️ Notice: This information collection may be referencing outdated material.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 (Revised): 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 10.23.19_title-xxi-state-plan-template_508_BH updates_clean.docx Form and Instruction
CMS-10398 #34 Crosswalk - Template Copy of Crosswalk Behavioral Health State Plan Update PRA_5.31.19.xlsx Form and Instruction
CMS-10398 #34 Track Changes - Template 10.23.19_title-xxi-state-plan-template_508_BH updates_track changes.docx Form and Instruction
#34 - Generic Supporting Statement (2019 version 2c).docx GenIC #34 - Generic Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #34 (Revised): 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	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	10.23.19_title-xxi-state-plan-template_508_BH updates_clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #34	Crosswalk - Template	Copy of Crosswalk Behavioral Health State Plan Update PRA_5.31.19.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #34	Track Changes - Template	10.23.19_title-xxi-state-plan-template_508_BH updates_track changes.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 41	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	1	1
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #34 - Generic Supporting Statement	#34 - Generic Supporting Statement (2019 version 2c).docx	11/07/2019

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