Information Collection

State Medicaid Eligibility Quality Control Sample Selection Lists and Supporting Regulations at 42 CFR 431.800 - 431.865

IC 43652 under ICR 202602-0938-007 · OMB 0938-0147.

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IC Title:	State Medicaid Eligibility Quality Control Sample Selection Lists and Supporting Regulations at 42 CFR 431.800 - 431.865	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 431.800 through 431.865

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	665	19	646
Annual IC Time Burden (Hours)	9,840	-54,760	64,600
Annual IC Cost Burden (Dollars)	0	0	0

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