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

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⚠️ Notice: This information collection may be referencing outdated material.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.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

Information Collection (IC) Details

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:

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 %

	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

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.