Information Collection

GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template

IC 271239 under ICR 202409-0938-028 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Eligbility-Processing-Data-Specs-July-2024.pdf	Other-Data Specifications
Eligbility-Processing-Data-Specs-July-2024.pdf	Other-Data Specifications
sho24002.pdf	Instruction
sho24002.pdf	Instruction
GenIC #66 Compliance Assessment and Plan for Federal Medicaid and Compliance Template (2024 version 1).pdf	Form and Instruction
GenIC #66 Compliance Assessment and Plan for Federal Medicaid and Compliance Template (2024 version 1).pdf	Form and Instruction
GenIC #66 Eligibility Processing Data Report portal screen shots Medicaid and CHIP Eligibility Process Data Portal.pdf	Form and Instruction
GenIC #66 Eligibility Processing Data Report portal screen shots Medicaid and CHIP Eligibility Process Data Portal.pdf	Form and Instruction
GenIC #66 Eligibility Processing Data Report excel workbook unwinding-data-rprt .pdf	Form and Instruction
GenIC #66 Eligibility Processing Data Report excel workbook unwinding-data-rprt .pdf	Form and Instruction
GenIC 66_Generic Supporting Statement_(2024 version 11 Combined SL and BN).docx Generic Supporting Statement	IC Document
GenIC 66_Generic Supporting Statement_(2024 version 11 Combined SL and BN).docx Generic Supporting Statement	IC Document
lzj-v3ej-219z - Comment.pdf Public Comment	IC Document
lzj-v3ej-219z - Comment.pdf Public Comment	IC Document
Response to Public Comments (Compliance Template) v2.docx Response to Public Comment	IC Document
Response to Public Comments (Compliance Template) v2.docx Response to Public Comment	IC Document

IC Title:

GenIC #66 (Extension from MACPro): Eligibility Processing Data Report and Renewal Compliance Template

Agency IC Tracking Number:

IC Status: New

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
Other-Data Specifications			Eligbility-Processing-Data-Specs-July-2024.pdf	Yes	Yes	Printable Only
Form and Instruction	GenIC #66	Compliance Assessment and Plan for Federal Medicaid and CHIP Renewal Requirements Template	Compliance Template (2024 version 1).pdf	Yes	Yes	Fillable Fileable
Instruction			sho24002.pdf	Yes	No	Printable Only
Form and Instruction	GenIC #66	Eligibility Processing Data Report portal screen shots	Medicaid and CHIP Eligibility Process Data Portal.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	GenIC #66	Eligibility Processing Data Report excel workbook	unwinding-data-rprt .pdf	Yes	Yes	Fillable Fileable

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	21,056	21,056
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	GenIC 66_Generic Supporting Statement_(2024 version 11 Combined SL and BN).docx	09/27/2024
Public Comment	lzj-v3ej-219z - Comment.pdf	09/27/2024
Response to Public Comment	Response to Public Comments (Compliance Template) v2.docx	09/27/2024

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