Information Collection

CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum

IC 241032 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10398.GenIC#11 CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum	Form and Instruction
CMS-10398.GenIC#11 CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_P CMS-10398#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-31-20).docx	Form and Instruction
CMS-10398.GenIC#11 CMS-10398.GenIC#11. MAGI-Based Eligibility Verification CMS-10398#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-31-20).docx	Form and Instruction
CMS-10398.GenIC#11 - MAGI-Based Eligibility Verification Plan Supporting Statement 2020 CLEAN Final (3-30-20).docx CMS-10398.GenIC#11 - MAGI-Based Eligibility Verification Plan Supporting Statement 2020 CLEAN Final (3-30-20)	IC Document

IC Title:

CMS-10398.GenIC#11 (revised) - MAGI-Based Eligibility Verification Plan Template and Addendum

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 435.940-960 42 CFR 457.380(j) 42 CFR 435.940-435.965

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398.GenIC#11	CMS-10398.GenIC#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-30-20)	CMS-10398#11.MAGI-Based Eligibility Verification_Plan_Template Final (3-31-20).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398.GenIC#11.	CMS-10398.GenIC#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-30-20)	CMS-10398#11. MAGI-Based Eligibility Verification Plan Attachment Disaster Ver Plan Addendum FINAL (3-31-20).docx		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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10398.GenIC#11 - MAGI-Based Eligibility Verification Plan Supporting Statement 2020 CLEAN Final (3-30-20)	CMS-10398.GenIC#11 - MAGI-Based Eligibility Verification Plan Supporting Statement 2020 CLEAN Final (3-30-20).docx	03/30/2020

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