CMS-10398 #17 Eligibility - Coverage From Conception to Birth

OMB Control Number 0938-1148

Separate Child Health Insurance Program
Eligibility – Coverage From Conception to Birth

CS9

42 CFR 457.10

Coverage From Conception to Birth – Coverage from conception to birth when the mother is not eligible for Medicaid.
☐The CHIP Agency operates this covered group in accordance with the following provisions.:
Age Standard
From conception through birth.
Does the state have an additional age definition or other age related conditions?

Choose an item.

Income Standards
Income standards are applied statewide.

Choose an item.

☐Exempted from requirement of providing or applying for a Social Security Number.
☐Exempted from requirement of verifying citizenship status.

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 OMB control number. The valid OMB 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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