CMS-10398 #17 Eligibility - Children Ineligible for Medicaid as a Resu

CHIP Eligibility
OMB Control Number: 0938‐1148

Child Health Insurance Program
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

CS14

Section 2101(f) of the ACA and 42 CFR 457.310(d)
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Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
The CHIP agency provides coverage for this group of children as follows:
The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to
Section 2101(f) such that no child in the state will be subject to this provision.
The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of
income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected
from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a
separate CHIP (expected to be no later than April 1, 2016 ).

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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