GenIC #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: 263409

Documents and Forms

Document Name Document Type
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form
Form CS3 GenIC #17 (Revision): CHIP State Plan Eligibility Form
CS3 Eligibility for Medicaid Expansion Program CS3.pdf Form
CS7 Eligibility - Targeted Low-Income Children CS7.pdf Form
CS8 Eligibility - Targeted Low-Income Pregnant Women CS8.pdf Form
CS9 Eligibility - Coverage From Conception to Birth CS9.pdf Form
CS10 Eligibility - Children Who Have Access to Public Employee Coverage CS10.pdf Form
CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage CS11.pdf Form
CS12 Eligibility - Dental Only Supplemental Coverage CS12.pdf Form
CS13 Eligibility - Deemed Newborns CS13.pdf Form
CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14.pdf Form
CS15 MAGI-Based Income Methodologies CS15.pdf Form
CS16 Other Eligibility Criteria – Spenddowns CS16.pdf Form
CS17 Non-Financial Eligibility – Residency CS17.pdf Form
CS18 Non-Financial Eligibility – Citizenship CS18.pdf Form
CS19 Non-Financial Eligibility - Social Security Number CS19.pdf Form
CS20 Non-Financial Eligibility - Substitution of Coverage CS20.pdf Form
CS21 Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf Form
CS23 Non-Financial Requirements - Other Eligibility Standards CS23.pdf Form
CS24 General Eligibility - Eligibility Processing CS24.pdf Form
CS27 (Revised) General Eligibility – Continuous Eligibility Updated CS27 Template_10.23.2023_clean.docx Form
CS28 General Eligibility - Presumptive Eligibility for Children CS28.pdf Form
CS29 General Eligibility - Presumptive Eligibility for Pregnant Women CS29.pdf Form
IG_CS3_MedicaidExpansion.docx Other-IG_CS3
IG_CS7_TargetedLow-IncomeChildren.docx Other-IG_CS7
IG_CS8_TargetedLow-IncomePregnantWomen.docx Other-IG_CS8
IG_CS9_CoverageFromConceptionToBirth.docx Other-IG_CS9
IG_CS10_ChildrenWhoHaveAccessToPublicEmployeeCoverage.docx Other-IG_CS10
IG_CS11_PregnantWomenWhoHaveAccessToPublicEmployeeCoverage.docx Other-IG_CS11
IG_CS12_DentalOnlySupplementalCoverage.docx Other-IG_CS12
IG_CS13_DeemedNewborns.docx Other-IG_CS13
IG_CS14_ChildrenIneligForMedicaid.docx Other-IG_CS14
IG_CS15_MAGI-BasedIncomeMethodologies.docx Other-IG_CS15
IG_CS16_Spenddown.docx Other-IG_CS16
IG_CS17_Non-Financial-Residency.docx Other-IG_CS17
IG_CS18_Non-Financial-Citizenship (2).docx Other-IG_CS18
IG_CS19_Non-Financial-SocialSecurityNumber.docx Other-IG_CS19
IG_CS20_Non-Financial-SubstitutionOfCoverage.docx Other-IG_CS20
IG_CS21_NonFinancialNonPaymentOfPremiums.docx Other-IG_CS21
IG_CS23_NonFinancialRequirementOtherEligibilityStandards.docx Other-IG_CS23
IG_CS24_EligibilityProcessing.docx Other-IG_CS24
IG CS27 10.23.23 clean.docx Other-IG_CS27 (Revised)
IG_CS28_PresumptiveEligibilityForChildren (1).docx Other-IG_CS28
IG_CS29_PresumptiveEligibilityForPregnantWomen.docx Other-IG_CS29
GenIC #17 - Generic Supporting Statement (2023 version 6) clean.docx Generic Supporting Statement IC Document
CS27 MMDL Template redline.docx Track Change: CS27 SPA Template IC Document
IG CS27 10.23.23 redline.docx Track Change: IG_CS27 IC Document
PRA CS27 Crosswalk 2023 Updates 10.23.23.xlsx Crosswalk: CS27 SPA Template IC Document
PRA CS27 IG Crosswalk Updates_10.29.2023.docx Crosswalk: IG_CS27 IC Document
sho23004.pdf (SHO #23-004) Continuous Eligibility for Children IC Document