[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10398 #34 Title XXI State Plan Template	Form and Instruction	Modified	Available
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries	Form	Modified	Available
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form	Modified	Available
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form	Modified	Available
Form CS27 General Eligibility – Continuous Eligibility	Form	Modified	Available
Form CS24 General Eligibility - Eligibility Processing	Form	Modified	Available
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form	Modified	Available
Form CS22 Retroactive Eligibility for Children and/or Pregnant Women	Form	Modified	Available
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form	Modified	Available
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form	Modified	Available
Form CS19 Non-Financial Eligibility - Social Security Number	Form	Modified	Available
Form CS18 Non-Financial Eligibility – Citizenship	Form	Modified	Available
Form CS17 Non-Financial Eligibility – Residency	Form	Modified	Available
Form CS16 Other Eligibility Criteria – Spenddowns	Form	Modified	Available
Form CS15 MAGI-Based Income Methodologies	Form	Modified	Available
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form	Modified	Available
Form CS13 Eligibility - Deemed Newborns	Form	Modified	Available
Form CS12 Eligibility - Dental Only Supplemental Coverage	Form	Modified	Available
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form	Modified	Available
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage	Form	Modified	Available
Form CS9 Eligibility - Coverage From Conception to Birth	Form	Modified	Available
Form CS8 Eligibility - Targeted Low-Income Pregnant Women	Form	Modified	Available
Form CS7 Eligibility - Targeted Low-Income Children	Form	Modified	Available
Form CS3 Eligibility for Medicaid Expansion Program	Form	Modified	Available
Form GenIC #34 Title XXI State Plan Template	Form and Instruction	Modified	Available
Form GenIC #99 Medicaid CCBHC Services SPA Coverage Template	Form and Instruction	Modified	Available
Form GenIC #66 Unwinding Eligibility and Enrollment Data Reporting Template	Form and Instruction	Modified	Available
Form GenIC #66 Data portal	Form and Instruction	Modified	Available
Form GenIC #66 Eligibility Processing Reports Portal Screen Shots	Form and Instruction	Modified	Available
Form GenIC #35 Eligibility and Enrollment Performance Indicators Template	Form and Instruction	Modified	Available
Form GenIC #11 MAGI Verification Plan Supplement: Community Engagement Guidance and Template	Form and Instruction	Modified	Available
Form GenIC #11 Disaster Relief MAGI-Based Verification Plan Addendum	Form and Instruction	Modified	Available
Form GenIC #11 MAGI-Based Eligibility Verification Plan Template	Form and Instruction	Modified	Available
Form See NOA GenICs Active as of 7-29-2026	Form and Instruction	Modified	Available
Justification for a Non-Substantive Change (2026 version 4).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2026-10-27	Available
CMS-10398 - Supporting Statement A (2026 version 5).docx	Supporting Statement A	Uploaded 2026-07-30	Available
CMS-10398 - Supporting Statement A (2026 version 5).docx	Supporting Statement A	Uploaded 2026-07-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
283152	[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Form and Instruction	Modified	Title XXI State Plan Template
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	General Eligibility - Incarcerated CHIP Beneficiaries
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	General Eligibility - Presumptive Eligibility for Pregnant Women
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	General Eligibility - Presumptive Eligibility for Children
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	General Eligibility – Continuous Eligibility
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	General Eligibility - Eligibility Processing
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Requirements - Other Eligibility Standards
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Retroactive Eligibility for Children and/or Pregnant Women
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Eligibility - Non-Payment of Premiums
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Eligibility - Substitution of Coverage
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Eligibility - Social Security Number
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Eligibility – Citizenship
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Non-Financial Eligibility – Residency
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Other Eligibility Criteria – Spenddowns
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	MAGI-Based Income Methodologies
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Deemed Newborns
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Dental Only Supplemental Coverage
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Children Who Have Access to Public Employee Coverage
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Coverage From Conception to Birth
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Targeted Low-Income Pregnant Women
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility - Targeted Low-Income Children
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form	Modified	Eligibility for Medicaid Expansion Program
281962	[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Instruction	Modified
281905	[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Form and Instruction	Modified	Title XXI State Plan Template
281883	[Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template	Form and Instruction	Modified	Medicaid CCBHC Services SPA Coverage Template
281680	GenIC #101 New (Medicaid Community Engagement: Short-term Hardship Exception Requests)		Modified
281679	GenIC #100 New (Medicaid Community Engagement: Good Faith Effort Exemptions and Quarterly Reporting)		Modified
281677	GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction	Modified	Unwinding Eligibility and Enrollment Data Reporting Template
281677	GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction	Modified	Data portal
281677	GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction	Modified	Eligibility Processing Reports Portal Screen Shots
281677	GenIC #66 Revised (Eligibility Processing Data Report)	Other-Eligibility Processing Data Report Specifications	Modified
281674	GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Form and Instruction	Modified	Eligibility and Enrollment Performance Indicators Template
281674	GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Other-Performance Indicators Data Dictionary	Modified
281673	GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction	Modified	MAGI Verification Plan Supplement: Community Engagement Guidance and Template
281673	GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction	Modified	Disaster Relief MAGI-Based Verification Plan Addendum
281673	GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction	Modified	MAGI-Based Eligibility Verification Plan Template
281672	Active GenICs (NOA issued 07-29-2026)	Form and Instruction	Modified	GenICs Active as of 7-29-2026

ICR Details

OMB Control No: 0938-1148	ICR Reference No: 202610-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202607-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: [Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/27/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	08/31/2029	08/31/2029
Responses	25,274	25,274
Time Burden (Hours)	1,572,707	1,562,707
Cost Burden (Dollars)	0	0

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Abstract: The Center for Medicaid, CHIP, and Survey & Certification in CMS works in partnership with States to implement Medicaid and the Children's Health Insurance Program (CHIP), and the Social Security Act requires written plans between CMS and the State to implement these programs. The Affordable Care Act enacted comprehensive reform that requires modification of existing programs. In addition to the Medicaid and CHIP State plans, CMS also continues to work with States through other methods to further the goals of health reform, including program waivers and demonstrations and other technical assistance initiatives and reporting. This collection will provide streamlined submission forms for States to implement health reform initiatives in Medicaid and CHIP state plans, demonstrations, and waivers, including legislative requirements enacted by the Affordable Care Act.

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Authorizing Statute(s): Statute at Large: 21 Stat. 1115
   Statute at Large: 19 Stat. 1901
   Statute at Large: 19 Stat. 1915
   Statute at Large: 21 Stat. 2101
  

Citations for New Statutory Requirements: Statute at Large: 19 Stat. 1915
Statute at Large: 21 Stat. 2101
Statute at Large: 21 Stat. 1115
Statute at Large: 19 Stat. 1901

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV98	Final or interim final rulemaking	91 FR 33348	06/03/2026

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 33348	06/03/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 33348	06/03/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Active GenICs (NOA issued 07-29-2026)	See NOA	GenICs Active as of 7-29-2026
GenIC #100 New (Medicaid Community Engagement: Good Faith Effort Exemptions and Quarterly Reporting)
GenIC #101 New (Medicaid Community Engagement: Short-term Hardship Exception Requests)
GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	GenIC #11, GenIC #11, GenIC #11	MAGI-Based Eligibility Verification Plan Template ,   Disaster Relief MAGI-Based Verification Plan Addendum ,   MAGI Verification Plan Supplement: Community Engagement Guidance and Template
GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	GenIC #35	Eligibility and Enrollment Performance Indicators Template
GenIC #66 Revised (Eligibility Processing Data Report)	GenIC #66, GenIC #66, GenIC #66	Eligibility Processing Reports Portal Screen Shots ,   Data portal ,   Unwinding Eligibility and Enrollment Data Reporting Template
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	CS27, CS28, CS29, CS31, CS3, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14, CS15, CS16, CS17, CS18, CS19, CS20, CS21, CS22, CS23, CS24	Eligibility for Medicaid Expansion Program ,   Eligibility - Targeted Low-Income Children ,   Eligibility - Targeted Low-Income Pregnant Women ,   Eligibility - Coverage From Conception to Birth ,   Eligibility - Children Who Have Access to Public Employee Coverage ,   Eligibility - Pregnant Women Who Have Access to Public Employee Coverage ,   Eligibility - Dental Only Supplemental Coverage ,   Eligibility - Deemed Newborns ,   Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards ,   MAGI-Based Income Methodologies ,   Other Eligibility Criteria – Spenddowns ,   Non-Financial Eligibility – Residency ,   Non-Financial Eligibility – Citizenship ,   Non-Financial Eligibility - Social Security Number ,   Non-Financial Eligibility - Substitution of Coverage ,   Non-Financial Eligibility - Non-Payment of Premiums ,   Retroactive Eligibility for Children and/or Pregnant Women ,   Non-Financial Requirements - Other Eligibility Standards ,   General Eligibility - Eligibility Processing ,   General Eligibility – Continuous Eligibility ,   General Eligibility - Presumptive Eligibility for Children ,   General Eligibility - Presumptive Eligibility for Pregnant Women ,   General Eligibility - Incarcerated CHIP Beneficiaries
[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	GenIC #34	Title XXI State Plan Template
[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	CMS-10398 #34	Title XXI State Plan Template
[Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template	GenIC #99	Medicaid CCBHC Services SPA Coverage Template

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,274	25,274	0	0	0	0
Annual Time Burden (Hours)	1,572,707	1,562,707	0	0	10,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We propose to increase our currently approved umbrella’s burden ceiling by 10,000 hours (from 1,562,707 to 1,572,707 hr).

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/27/2026

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