Information Collection

GenIC #17 (Revision): CHIP State Plan Eligibility

IC 263409 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⚠️ Notice: This information collection may be referencing outdated material.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 CS3 GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS3 Eligibility for Medicaid Expansion Program GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS7 Eligibility - Targeted Low-Income Children GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS8 Eligibility - Targeted Low-Income Pregnant Women GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS9 Eligibility - Coverage From Conception to Birth GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS12 Eligibility - Dental Only Supplemental Coverage GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS13 Eligibility - Deemed Newborns GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS15 MAGI-Based Income Methodologies GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS16 Other Eligibility Criteria – Spenddowns GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS17 Non-Financial Eligibility – Residency GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS18 Non-Financial Eligibility – Citizenship GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS19 Non-Financial Eligibility - Social Security Number GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS20 Non-Financial Eligibility - Substitution of Coverage GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS23 Non-Financial Requirements - Other Eligibility Standards GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS24 General Eligibility - Eligibility Processing GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS27 (Revised) General Eligibility – Continuous Eligibility GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS28 General Eligibility - Presumptive Eligibility for Children GenIC #17 (Revision): CHIP State Plan Eligibility	Form
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women GenIC #17 (Revision): CHIP State Plan Eligibility	Form
IG_CS3_MedicaidExpansion.docx	Other-IG_CS3
IG_CS3_MedicaidExpansion.docx	Other-IG_CS3
IG_CS7_TargetedLow-IncomeChildren.docx	Other-IG_CS7
IG_CS7_TargetedLow-IncomeChildren.docx	Other-IG_CS7
IG_CS8_TargetedLow-IncomePregnantWomen.docx	Other-IG_CS8
IG_CS8_TargetedLow-IncomePregnantWomen.docx	Other-IG_CS8
IG_CS9_CoverageFromConceptionToBirth.docx	Other-IG_CS9
IG_CS9_CoverageFromConceptionToBirth.docx	Other-IG_CS9
IG_CS10_ChildrenWhoHaveAccessToPublicEmployeeCoverage.docx	Other-IG_CS10
IG_CS10_ChildrenWhoHaveAccessToPublicEmployeeCoverage.docx	Other-IG_CS10
IG_CS11_PregnantWomenWhoHaveAccessToPublicEmployeeCoverage.docx	Other-IG_CS11
IG_CS11_PregnantWomenWhoHaveAccessToPublicEmployeeCoverage.docx	Other-IG_CS11
IG_CS12_DentalOnlySupplementalCoverage.docx	Other-IG_CS12
IG_CS12_DentalOnlySupplementalCoverage.docx	Other-IG_CS12
IG_CS13_DeemedNewborns.docx	Other-IG_CS13
IG_CS13_DeemedNewborns.docx	Other-IG_CS13
IG_CS14_ChildrenIneligForMedicaid.docx	Other-IG_CS14
IG_CS14_ChildrenIneligForMedicaid.docx	Other-IG_CS14
IG_CS15_MAGI-BasedIncomeMethodologies.docx	Other-IG_CS15
IG_CS15_MAGI-BasedIncomeMethodologies.docx	Other-IG_CS15
IG_CS16_Spenddown.docx	Other-IG_CS16
IG_CS16_Spenddown.docx	Other-IG_CS16
IG_CS17_Non-Financial-Residency.docx	Other-IG_CS17
IG_CS17_Non-Financial-Residency.docx	Other-IG_CS17
IG_CS18_Non-Financial-Citizenship (2).docx	Other-IG_CS18
IG_CS18_Non-Financial-Citizenship (2).docx	Other-IG_CS18
IG_CS19_Non-Financial-SocialSecurityNumber.docx	Other-IG_CS19
IG_CS19_Non-Financial-SocialSecurityNumber.docx	Other-IG_CS19
IG_CS20_Non-Financial-SubstitutionOfCoverage.docx	Other-IG_CS20
IG_CS20_Non-Financial-SubstitutionOfCoverage.docx	Other-IG_CS20
IG_CS21_NonFinancialNonPaymentOfPremiums.docx	Other-IG_CS21
IG_CS21_NonFinancialNonPaymentOfPremiums.docx	Other-IG_CS21
IG_CS23_NonFinancialRequirementOtherEligibilityStandards.docx	Other-IG_CS23
IG_CS23_NonFinancialRequirementOtherEligibilityStandards.docx	Other-IG_CS23
IG_CS24_EligibilityProcessing.docx	Other-IG_CS24
IG_CS24_EligibilityProcessing.docx	Other-IG_CS24
IG CS27 10.23.23 clean.docx	Other-IG_CS27 (Revised)
IG CS27 10.23.23 clean.docx	Other-IG_CS27 (Revised)
IG_CS28_PresumptiveEligibilityForChildren (1).docx	Other-IG_CS28
IG_CS28_PresumptiveEligibilityForChildren (1).docx	Other-IG_CS28
IG_CS29_PresumptiveEligibilityForPregnantWomen.docx	Other-IG_CS29
IG_CS29_PresumptiveEligibilityForPregnantWomen.docx	Other-IG_CS29
CS3 Eligibility for Medicaid Expansion Program CS3.pdf	Form
CS3 Eligibility for Medicaid Expansion Program CS3.pdf	Form
CS7 Eligibility - Targeted Low-Income Children CS7.pdf	Form
CS7 Eligibility - Targeted Low-Income Children CS7.pdf	Form
CS8 Eligibility - Targeted Low-Income Pregnant Women CS8.pdf	Form
CS8 Eligibility - Targeted Low-Income Pregnant Women CS8.pdf	Form
CS9 Eligibility - Coverage From Conception to Birth CS9.pdf	Form
CS9 Eligibility - Coverage From Conception to Birth CS9.pdf	Form
CS10 Eligibility - Children Who Have Access to Public Employe CS10.pdf	Form
CS10 Eligibility - Children Who Have Access to Public Employe CS10.pdf	Form
CS11 Eligibility - Pregnant Women Who Have Access to Public E CS11.pdf	Form
CS11 Eligibility - Pregnant Women Who Have Access to Public E CS11.pdf	Form
CS12 Eligibility - Dental Only Supplemental Coverage CS12.pdf	Form
CS12 Eligibility - Dental Only Supplemental Coverage CS12.pdf	Form
CS13 Eligibility - Deemed Newborns CS13.pdf	Form
CS13 Eligibility - Deemed Newborns CS13.pdf	Form
CS14 Eligibility - Children Ineligible for Medicaid as a Resu CS14.pdf	Form
CS14 Eligibility - Children Ineligible for Medicaid as a Resu CS14.pdf	Form
CS15 MAGI-Based Income Methodologies CS15.pdf	Form
CS15 MAGI-Based Income Methodologies CS15.pdf	Form
CS16 Other Eligibility Criteria – Spenddowns CS16.pdf	Form
CS16 Other Eligibility Criteria – Spenddowns CS16.pdf	Form
CS17 Non-Financial Eligibility – Residency CS17.pdf	Form
CS17 Non-Financial Eligibility – Residency CS17.pdf	Form
CS18 Non-Financial Eligibility – Citizenship CS18.pdf	Form
CS18 Non-Financial Eligibility – Citizenship CS18.pdf	Form
CS19 Non-Financial Eligibility - Social Security Number CS19.pdf	Form
CS19 Non-Financial Eligibility - Social Security Number CS19.pdf	Form
CS20 Non-Financial Eligibility - Substitution of Coverage CS20.pdf	Form
CS20 Non-Financial Eligibility - Substitution of Coverage CS20.pdf	Form
CS21 Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf	Form
CS21 Non-Financial Eligibility - Non-Payment of Premiums CS21.pdf	Form
CS23 Non-Financial Requirements - Other Eligibility Standards CS23.pdf	Form
CS23 Non-Financial Requirements - Other Eligibility Standards CS23.pdf	Form
CS24 General Eligibility - Eligibility Processing CS24.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
CS27 (Revised) General Eligibility – Continuous Eligibility Updated CS27 Template_10.23.2023_clean.docx	Form
CS28 General Eligibility - Presumptive Eligibility for Childr CS28.pdf	Form
CS28 General Eligibility - Presumptive Eligibility for Childr CS28.pdf	Form
CS29 General Eligibility - Presumptive Eligibility for Pregna CS29.pdf	Form
CS29 General Eligibility - Presumptive Eligibility for Pregna CS29.pdf	Form
GenIC #17 - Generic Supporting Statement (2023 version 6) clean.docx Generic Supporting Statement	IC Document
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
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
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 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
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
sho23004.pdf (SHO #23-004) Continuous Eligibility for Children	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CS3	Yes	Yes	Fillable Fileable
Form	CS7	Yes	Yes	Fillable Fileable
Form	CS8	Yes	Yes	Fillable Fileable
Form	CS9	Yes	Yes	Fillable Fileable
Form	CS10	Yes	Yes	Fillable Fileable
Form	CS11	Yes	Yes	Fillable Fileable
Form	CS12	Yes	Yes	Fillable Fileable
Form	CS13	Yes	Yes	Fillable Fileable
Form	CS14	Yes	Yes	Fillable Fileable
Form	CS15	Yes	Yes	Fillable Fileable
Form	CS16	Yes	Yes	Fillable Fileable
Form	CS17	Yes	Yes	Fillable Fileable
Form	CS18	Yes	Yes	Fillable Fileable
Form	CS19	Yes	Yes	Fillable Fileable
Form	CS20	Yes	Yes	Fillable Fileable
Form	CS21	Yes	Yes	Fillable Fileable
Form	CS23	Yes	Yes	Fillable Fileable
Form	CS24	Yes	Yes	Fillable Fileable
Form	CS27 (Revised)	Yes	Yes	Fillable Fileable
Form	CS28	Yes	Yes	Fillable Fileable
Form	CS29	Yes	Yes	Fillable Fileable
Other-IG_CS3		Yes	No	Printable Only
Other-IG_CS7		Yes	No	Printable Only
Other-IG_CS8		Yes	No	Printable Only
Other-IG_CS9		Yes	No	Printable Only
Other-IG_CS10		Yes	No	Printable Only
Other-IG_CS11		Yes	No	Printable Only
Other-IG_CS12		Yes	No	Printable Only
Other-IG_CS13		Yes	No	Printable Only
Other-IG_CS14		Yes	No	Printable Only
Other-IG_CS15		Yes	No	Printable Only
Other-IG_CS16		Yes	No	Printable Only
Other-IG_CS17		Yes	No	Printable Only
Other-IG_CS18		Yes	No	Printable Only
Other-IG_CS19		Yes	No	Printable Only
Other-IG_CS20		Yes	No	Printable Only
Other-IG_CS21		Yes	No	Printable Only
Other-IG_CS23		Yes	No	Fillable Fileable
Other-IG_CS24		Yes	No	Fillable Fileable
Other-IG_CS27 (Revised)		Yes	No	Printable Only
Other-IG_CS28		Yes	No	Printable Only
Other-IG_CS29		Yes	No	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
Generic Supporting Statement		11/14/2023
Track Change: CS27 SPA Template		11/14/2023
Track Change: IG_CS27		11/14/2023
Crosswalk: CS27 SPA Template		11/14/2023
Crosswalk: IG_CS27		11/14/2023
(SHO #23-004) Continuous Eligibility for Children		11/14/2023

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

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