Information Collection

#17 (Revision): CHIP State Plan Eligibility

IC 251152 under ICR 202401-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
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 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 Children CS7.pdf	Form
CMS-10398 #17 Eligibility - Targeted Low-Income Pregnant Women CS8.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 - Coverage From Conception to Birth CS9.pdf	Form
CMS-10398 #17 Eligibility - Children Who Have Access to Public Employe CS10.pdf	Form
CMS-10398 #17 Eligibility - Children Who Have Access to Public Employe CS10.pdf	Form
CMS-10398 #17 Eligibility - Pregnant Women Who Have Access to Public E CS11.pdf	Form
CMS-10398 #17 Eligibility - Pregnant Women Who Have Access to Public E CS11.pdf	Form
CMS-10398 #17 Eligibility - Dental Only Supplemental Coverage CS12.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 - Deemed Newborns CS13.pdf	Form
CMS-10398 #17 Eligibility - Children Ineligible for Medicaid as a Resu CS14.pdf	Form
CMS-10398 #17 Eligibility - Children Ineligible for Medicaid as a Resu CS14.pdf	Form
CMS-10398 #17 MAGI-Based Income Methodologies CS15.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 Other Eligibility Criteria – Spenddowns CS16.pdf	Form
CMS-10398 #17 Non-Financial Eligibility – Residency CS17.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 – Citizenship (Reinstatement) CS18.pdf	Form
CMS-10398 #17 Non-Financial Eligibility - Social Security Number CS19.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 - Substitution of Coverage CS20.pdf	Form
CMS-10398 #17 Non-Financial Eligibility - Non-Payment of Premiums CS21.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 Non-Financial Requirements - Other Eligibility Standards CS23.pdf	Form
CMS-10398 #17 General Eligibility - Eligibility Processing CS24.pdf	Form
CMS-10398 #17 General Eligibility - Eligibility Processing CS24.pdf	Form
CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards CS27 - Revised.pdf	Form
CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards CS27 - Revised.pdf	Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Childr CS28.pdf	Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Childr CS28.pdf	Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Pregna CS29.pdf	Form
CMS-10398 #17 General Eligibility - Presumptive Eligibility for Pregna CS29.pdf	Form
CS27 Crosswalk.xlsx Crosswalk: CS27 (Non-Financial Requirements - Other Eligibility Standards)	IC Document
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
17 - Generic Supporting Statement (2022 version 6).docx #17 Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

#17 (Revision): CHIP State Plan Eligibility

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #17	Eligibility for Medicaid Expansion Program	CS3.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Targeted Low-Income Children	CS7.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Targeted Low-Income Pregnant Women	CS8.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Coverage From Conception to Birth	CS9.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Children Who Have Access to Public Employee Coverage	CS10.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	CS11.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Dental Only Supplemental Coverage	CS12.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Deemed Newborns	CS13.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	CS14.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	MAGI-Based Income Methodologies	CS15.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Other Eligibility Criteria â Spenddowns	CS16.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Eligibility â Residency	CS17.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Eligibility â Citizenship (Reinstatement)	CS18.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Eligibility - Social Security Number	CS19.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Eligibility - Substitution of Coverage	CS20.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Eligibility - Non-Payment of Premiums	CS21.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Requirements - Other Eligibility Standards	CS23.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	General Eligibility - Eligibility Processing	CS24.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	Non-Financial Requirements - Other Eligibility Standards (Revised)	CS27 - Revised.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	General Eligibility - Presumptive Eligibility for Children	CS28.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #17	General Eligibility - Presumptive Eligibility for Pregnant Women	CS29.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: CS27 (Non-Financial Requirements - Other Eligibility Standards)	CS27 Crosswalk.xlsx	02/03/2022
#17 Generic Supporting Statement	17 - Generic Supporting Statement (2022 version 6).docx	02/03/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.