Form CMS-10398 #17 CMS-10398 #17 Eligibility for Medicaid Expansion Program

CHIP Eligibility
Olv.lB Control Number 0938-1148

Eligibility for Medicaid Expansion Program

CS3

42 CFR 457.320(a)(2) and (3)
Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards:
There should be no overlaps or gaps for the ages entered.
Age and Household Income Ranges

+

I

From Age

II

To Age

I

Above (% FPL)

Up to & including (% FPL)

X

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid Ol\ffi control number. The valid OJ\1B control number for this information collection is 0938-1148 (CMS-10398 #17). The time
required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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