#17 (Revision): CHIP State Plan Eligibility

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

OMB: 0938-1148

IC ID: 251152

Documents and Forms

Document Name Document Type
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form
Form CMS-10398 #17 #17 (Revision): CHIP State Plan Eligibility Form
CMS-10398 #17 Eligibility for Medicaid Expansion Program CS3.pdf Form
CMS-10398 #17 Eligibility - Targeted Low-Income Children CS7.pdf Form
CMS-10398 #17 Eligibility - Targeted Low-Income Pregnant Women CS8.pdf Form
CMS-10398 #17 Eligibility - Coverage From Conception to Birth CS9.pdf Form
CMS-10398 #17 Eligibility - Children Who Have Access to Public Employee Coverage CS10.pdf Form
CMS-10398 #17 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage CS11.pdf Form
CMS-10398 #17 Eligibility - Dental Only Supplemental Coverage CS12.pdf Form
CMS-10398 #17 Eligibility - Deemed Newborns CS13.pdf Form
CMS-10398 #17 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14.pdf Form
CMS-10398 #17 MAGI-Based Income Methodologies CS15.pdf Form
CMS-10398 #17 Other Eligibility Criteria – Spenddowns CS16.pdf Form
CMS-10398 #17 Non-Financial Eligibility – Residency CS17.pdf Form
CMS-10398 #17 Non-Financial Eligibility – Citizenship (Reinstatement) CS18.pdf Form
CMS-10398 #17 Non-Financial Eligibility - Social Security Number CS19.pdf Form
CMS-10398 #17 Non-Financial Eligibility - Substitution of Coverage CS20.pdf Form
CMS-10398 #17 Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf Form
CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards CS23.pdf Form
CMS-10398 #17 General Eligibility - Eligibility Processing CS24.pdf Form
CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards (Revised) CS27 - Revised.pdf Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Children CS28.pdf Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Pregnant Women CS29.pdf Form
CS27 Crosswalk.xlsx Crosswalk: CS27 (Non-Financial Requirements - Other Eligibility Standards) IC Document
17 - Generic Supporting Statement (2022 version 6).docx #17 Generic Supporting Statement IC Document