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Federal forms, ICRs, and supporting documents

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GenIC #17 (Revision): CHIP State Plan Eligibility

IC 263409 under ICR 202401-0938-016 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Form
Form
Other-IG_CS3
Other-IG_CS3
Other-IG_CS7
Other-IG_CS7
Other-IG_CS8
Other-IG_CS8
Other-IG_CS9
Other-IG_CS9
Other-IG_CS10
Other-IG_CS10
Other-IG_CS11
Other-IG_CS11
Other-IG_CS12
Other-IG_CS12
Other-IG_CS13
Other-IG_CS13
Other-IG_CS14
Other-IG_CS14
Other-IG_CS15
Other-IG_CS15
Other-IG_CS16
Other-IG_CS16
Other-IG_CS17
Other-IG_CS17
Other-IG_CS18
Other-IG_CS18
Other-IG_CS19
Other-IG_CS19
Other-IG_CS20
Other-IG_CS20
Other-IG_CS21
Other-IG_CS21
Other-IG_CS23
Other-IG_CS23
Other-IG_CS24
Other-IG_CS24
Other-IG_CS27 (Revised)
Other-IG_CS27 (Revised)
Other-IG_CS28
Other-IG_CS28
Other-IG_CS29
Other-IG_CS29
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IC Document
IC Document
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Information Collection (IC) Details

View Information Collection (IC)

GenIC #17 (Revision): CHIP State Plan Eligibility CMCS
 
Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CS3 Eligibility for Medicaid Expansion Program CS3.pdf Yes Yes Fillable Fileable
Form CS7 Eligibility - Targeted Low-Income Children CS7.pdf Yes Yes Fillable Fileable
Form CS8 Eligibility - Targeted Low-Income Pregnant Women CS8.pdf Yes Yes Fillable Fileable
Form CS9 Eligibility - Coverage From Conception to Birth CS9.pdf Yes Yes Fillable Fileable
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage CS10.pdf Yes Yes Fillable Fileable
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage CS11.pdf Yes Yes Fillable Fileable
Form CS12 Eligibility - Dental Only Supplemental Coverage CS12.pdf Yes Yes Fillable Fileable
Form CS13 Eligibility - Deemed Newborns CS13.pdf Yes Yes Fillable Fileable
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14.pdf Yes Yes Fillable Fileable
Form CS15 MAGI-Based Income Methodologies CS15.pdf Yes Yes Fillable Fileable
Form CS16 Other Eligibility Criteria – Spenddowns CS16.pdf Yes Yes Fillable Fileable
Form CS17 Non-Financial Eligibility – Residency CS17.pdf Yes Yes Fillable Fileable
Form CS18 Non-Financial Eligibility – Citizenship CS18.pdf Yes Yes Fillable Fileable
Form CS19 Non-Financial Eligibility - Social Security Number CS19.pdf Yes Yes Fillable Fileable
Form CS20 Non-Financial Eligibility - Substitution of Coverage CS20.pdf Yes Yes Fillable Fileable
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf Yes Yes Fillable Fileable
Form CS23 Non-Financial Requirements - Other Eligibility Standards CS23.pdf Yes Yes Fillable Fileable
Form CS24 General Eligibility - Eligibility Processing CS24.pdf Yes Yes Fillable Fileable
Form CS27 (Revised) General Eligibility – Continuous Eligibility Updated CS27 Template_10.23.2023_clean.docx Yes Yes Fillable Fileable
Form CS28 General Eligibility - Presumptive Eligibility for Children CS28.pdf Yes Yes Fillable Fileable
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women CS29.pdf Yes Yes Fillable Fileable
Other-IG_CS3 IG_CS3_MedicaidExpansion.docx Yes No Printable Only
Other-IG_CS7 IG_CS7_TargetedLow-IncomeChildren.docx Yes No Printable Only
Other-IG_CS8 IG_CS8_TargetedLow-IncomePregnantWomen.docx Yes No Printable Only
Other-IG_CS9 IG_CS9_CoverageFromConceptionToBirth.docx Yes No Printable Only
Other-IG_CS10 IG_CS10_ChildrenWhoHaveAccessToPublicEmployeeCoverage.docx Yes No Printable Only
Other-IG_CS11 IG_CS11_PregnantWomenWhoHaveAccessToPublicEmployeeCoverage.docx Yes No Printable Only
Other-IG_CS12 IG_CS12_DentalOnlySupplementalCoverage.docx Yes No Printable Only
Other-IG_CS13 IG_CS13_DeemedNewborns.docx Yes No Printable Only
Other-IG_CS14 IG_CS14_ChildrenIneligForMedicaid.docx Yes No Printable Only
Other-IG_CS15 IG_CS15_MAGI-BasedIncomeMethodologies.docx Yes No Printable Only
Other-IG_CS16 IG_CS16_Spenddown.docx Yes No Printable Only
Other-IG_CS17 IG_CS17_Non-Financial-Residency.docx Yes No Printable Only
Other-IG_CS18 IG_CS18_Non-Financial-Citizenship (2).docx Yes No Printable Only
Other-IG_CS19 IG_CS19_Non-Financial-SocialSecurityNumber.docx Yes No Printable Only
Other-IG_CS20 IG_CS20_Non-Financial-SubstitutionOfCoverage.docx Yes No Printable Only
Other-IG_CS21 IG_CS21_NonFinancialNonPaymentOfPremiums.docx Yes No Printable Only
Other-IG_CS23 IG_CS23_NonFinancialRequirementOtherEligibilityStandards.docx Yes No Fillable Fileable
Other-IG_CS24 IG_CS24_EligibilityProcessing.docx Yes No Fillable Fileable
Other-IG_CS27 (Revised) IG CS27 10.23.23 clean.docx Yes No Printable Only
Other-IG_CS28 IG_CS28_PresumptiveEligibilityForChildren (1).docx Yes No Printable Only
Other-IG_CS29 IG_CS29_PresumptiveEligibilityForPregnantWomen.docx Yes No Fillable Fileable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 56
Annual IC Time Burden (Hours) 5 0 0 0 0 5
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC #17 - Generic Supporting Statement (2023 version 6) clean.docx 11/14/2023
Track Change: CS27 SPA Template CS27 MMDL Template redline.docx 11/14/2023
Track Change: IG_CS27 IG CS27 10.23.23 redline.docx 11/14/2023
Crosswalk: CS27 SPA Template PRA CS27 Crosswalk 2023 Updates 10.23.23.xlsx 11/14/2023
Crosswalk: IG_CS27 PRA CS27 IG Crosswalk Updates_10.29.2023.docx 11/14/2023
(SHO #23-004) Continuous Eligibility for Children sho23004.pdf 11/14/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.