OMB control number
1932 State Plan Amendment Template (CMS-10120)
OMB 0938-0933 ยท HHS/CMS.
OMB 0938-0933
The State Medicaid Agencies will complete the template. CMS will review the information to determine if the state has met all the requirements under 1932(a)(1)(A) and 42 CFR 438.50. Once the all the requirements are met, the state will be allowed to enroll Medicaid beneficiaries on a mandatory basis into managed care entities without section 1115 or 1915(b) waiver authority.
The latest form for 1932 State Plan Amendment Template (CMS-10120) expires 2020-06-30 and is listed under ICR 201704-0938-005.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10120 1932 State Plan Amendment Template | Form |
 CMS-10120 - Supporting Statement A [rev 04-21-2017 by OSORA PRA].docx | Supporting Statement A |
 1932 State Plan Amendment Template |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201704-0938-005 | Revision of a currently approved collection | 2017-04-21 | Approved without change | |
| 201402-0938-014 | Revision of a currently approved collection | 2014-02-26 | Approved without change | |
| 201102-0938-014 | Extension without change of a currently approved collection | 2011-02-28 | Approved without change | |
| 200801-0938-008 | Extension without change of a currently approved collection | 2008-01-16 | Approved without change | |
| 200411-0938-001 | New collection (Request for a new OMB Control Number) | 2004-11-01 | Approved with change |