CMS-10398 #17 Other Eligibility Criteria – Spenddowns

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Other Eligibility Criteria - Spenddowns

CS16

Does the state apply a Spenddown process for any of the covered population groups
whose household income exceeds the CHIP qualifying income limit?

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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