[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility

Documents and forms in this information collection

Document Name	Document Type
Form CS3 Eligibility for Medicaid Expansion Program [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS7 Eligibility - Targeted Low-Income Children [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS8 Eligibility - Targeted Low-Income Pregnant Women [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS9 Eligibility - Coverage From Conception to Birth [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS12 Eligibility - Dental Only Supplemental Coverage [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS13 Eligibility - Deemed Newborns [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS15 MAGI-Based Income Methodologies [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS16 Other Eligibility Criteria – Spenddowns [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS17 Non-Financial Eligibility – Residency [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS18 Non-Financial Eligibility – Citizenship [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS19 Non-Financial Eligibility - Social Security Number [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS20 Non-Financial Eligibility - Substitution of Coverage [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS23 Non-Financial Requirements - Other Eligibility Standards [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS24 General Eligibility - Eligibility Processing [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS27 General Eligibility – Continuous Eligibility [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS28 General Eligibility - Presumptive Eligibility for Children [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries [Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
IG_ChipEligibilityIntroduction - CLEAN.pdf	Other-Introduction to the IG
IG_CS3_MedicaidExpansion.pdf	Other-IG (CS3) Eligibility for Medic
IG_CS7_TargetedLow-IncomeChildren.pdf	Other-IG (CS7) Eligibility - Targete
IG_CS8_TargetedLow-IncomePregnantWomen.pdf	Other-IG (CS8) Eligibility - Targete
IG_CS9_CoverageFromConceptionToBirth.pdf	Other-IG (CS9) Eligibility - Coverag
IG_CS10_ChildrenWhoHaveAccessToPublicEmployeeCoverage.pdf	Other-IG (CS10) Eligibility - Childr
IG_CS11_PregnantWomenWhoHaveAccessToPublicEmployeeCoverage.pdf	Other-IG (CS11) Eligibility - Pregna
IG_CS12_DentalOnlySupplementalCoverage.pdf	Other-IG (CS12) Eligibility - Dental
IG_CS13_DeemedNewborns.pdf	Other-IG (CS13) Eligibility - Deemed
IG_CS14_ChildrenIneligForMedicaid.pdf	Other-IG (CS14) Eligibility - Childr
IG_CS15_MAGI-BasedIncomeMethodologies.pdf	Other-IG (CS15) MAGI-Based Income Me
IG_CS16_Spenddown.pdf	Other-IG (CS16) Other Eligibility Cr
IG_CS17_Non-Financial-Residency.pdf	Other-IG (CS17) Non-Financial Eligib
IG_CS18_Non-Financial-Citizenship.pdf	Other-IG (CS18) Non-Financial Eligib
IG_CS19_Non-Financial-SocialSecurityNumber.pdf	Other-IG (CS19) Non-Financial Eligib
IG_CS20_Non-Financial-SubstitutionOfCoverage.pdf	Other-IG (CS20) Non-Financial Eligib
IG_CS21_NonFinancialNonPaymentOfPremiums.pdf	Other-IG (CS21) Non-Financial Eligib
IG_CS23_NonFinancialRequirementOtherEligibilityStandards.pdf	Other-IG (CS23) Non-Financial Requir
IG_CS24_EligibilityProcessing.pdf	Other-IG (CS24) General Eligibility
IG_CS27_ContinuousEligibility.pdf	Other-IG (CS27) General Eligibility
IG_CS28_PresumptiveEligibilityForChildren.pdf	Other-IG (CS28) General Eligibility
IG_CS29_PresumptiveEligibilityForPregnantWomen.pdf	Other-IG (CS29) General Eligibility
IG_CS31-Incarcerated CHIP Beneficiaries508.pdf	Other-IG (CS31) General Eligibility
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 Employe CS10.pdf	Form
CS11 Eligibility - Pregnant Women Who Have Access to Public E 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 Resu 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 General Eligibility – Continuous Eligibility CS27.pdf	Form
CS28 General Eligibility - Presumptive Eligibility for Childr CS28.pdf	Form
CS29 General Eligibility - Presumptive Eligibility for Pregna CS29.pdf	Form
CS31 General Eligibility - Incarcerated CHIP Beneficiaries CS31.pdf	Form
GenIC 17 - Generic Supporting Statement (2025 version 9).docx Generic Supporting Statement	IC Document
IG_ChipEligibilityIntroduction - REDLINE.pdf REDLINE - Introduction to the Implementation Guides (IGs)	IC Document

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