OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

1932 State Plan Amendment Template (CMS-10120)

OMB 0938-0933 · 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 can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Supporting Statement A
All Historical Document Collections
Approved without change
 Revision of a currently approved collection 2017-04-21
Approved without change
 Revision of a currently approved collection 2014-02-26
Approved without change
 Extension without change of a currently approved collection 2011-02-28
Approved without change
 Extension without change of a currently approved collection 2008-01-16
Approved with change
 New collection (Request for a new OMB Control Number) 2004-11-01