OMB control number

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

OMB 0938-1148 · HHS/CMS.

OMB 0938-1148

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.

The latest form for [Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398) expires 2029-08-31 and is listed under ICR 202607-0938-014.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form CMS-10398 #34 Title XXI State Plan Template	Form and Instruction
Form CS31 General Eligibility - Incarcerated CHIP Beneficiaries	Form
Form CS29 General Eligibility - Presumptive Eligibility for Pregnant Women	Form
Form CS28 General Eligibility - Presumptive Eligibility for Children	Form
Form CS27 General Eligibility – Continuous Eligibility	Form
Form CS24 General Eligibility - Eligibility Processing	Form
Form CS23 Non-Financial Requirements - Other Eligibility Standards	Form
Form CS22 Retroactive Eligibility for Children and/or Pregnant Women	Form
Form CS21 Non-Financial Eligibility - Non-Payment of Premiums	Form
Form CS20 Non-Financial Eligibility - Substitution of Coverage	Form
Form CS19 Non-Financial Eligibility - Social Security Number	Form
Form CS18 Non-Financial Eligibility – Citizenship	Form
Form CS17 Non-Financial Eligibility – Residency	Form
Form CS16 Other Eligibility Criteria – Spenddowns	Form
Form CS15 MAGI-Based Income Methodologies	Form
Form CS14 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards	Form
Form CS13 Eligibility - Deemed Newborns	Form
Form CS12 Eligibility - Dental Only Supplemental Coverage	Form
Form CS11 Eligibility - Pregnant Women Who Have Access to Public Employee Coverage	Form
Form CS10 Eligibility - Children Who Have Access to Public Employee Coverage	Form
Form CS9 Eligibility - Coverage From Conception to Birth	Form
Form CS8 Eligibility - Targeted Low-Income Pregnant Women	Form
Form CS7 Eligibility - Targeted Low-Income Children	Form
Form CS3 Eligibility for Medicaid Expansion Program	Form
Form GenIC #34 Title XXI State Plan Template	Form and Instruction
Form GenIC #99 Medicaid CCBHC Services SPA Coverage Template	Form and Instruction
Form GenIC #66 Unwinding Eligibility and Enrollment Data Reporting Template	Form and Instruction
Form GenIC #66 Data portal	Form and Instruction
Form GenIC #66 Eligibility Processing Reports Portal Screen Shots	Form and Instruction
Form GenIC #35 Eligibility and Enrollment Performance Indicators Template	Form and Instruction
Form GenIC #11 MAGI Verification Plan Supplement: Community Engagement Guidance and Template	Form and Instruction
Form GenIC #11 Disaster Relief MAGI-Based Verification Plan Addendum	Form and Instruction
Form GenIC #11 MAGI-Based Eligibility Verification Plan Template	Form and Instruction
Form See NOA GenICs Active as of 7-29-2026	Form and Instruction
Justification for a Non-Substantive Change (2026 version 4).docx	Justification for No Material/Nonsubstantive Change
CMS-10398 - Supporting Statement A (2026 version 5).docx	Supporting Statement A
CMS-10398 - Supporting Statement A (2026 version 5).docx	Supporting Statement A
[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
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Form
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Instruction
[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
[Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template	Form and Instruction
GenIC #101 New (Medicaid Community Engagement: Short-term Hardship Exception Requests)	Information collection
GenIC #100 New (Medicaid Community Engagement: Good Faith Effort Exemptions and Quarterly Reporting)	Information collection
GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
GenIC #66 Revised (Eligibility Processing Data Report)	Other-Eligibility Processing Data Report Specifications
GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Form and Instruction
GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Other-Performance Indicators Data Dictionary
GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction
GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction
GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Form and Instruction
Active GenICs (NOA issued 07-29-2026)	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202610-0938-013	No material or nonsubstantive change to a currently approved collection	2026-10-27
202607-0938-014	Revision of a currently approved collection	2026-07-30
202409-0938-028	Reinstatement with change of a previously approved collection	2024-09-27	Approved without change
202407-0938-005	Reinstatement without change of a previously approved collection	2024-07-11	Improperly submitted
202401-0938-016	No material or nonsubstantive change to a currently approved collection	2024-01-30	Approved without change
202103-0938-018	Revision of a currently approved collection	2021-03-23	Approved with change
201712-0938-019	Revision of a currently approved collection	2017-12-29	Approved with change
201410-0938-016	Revision of a currently approved collection	2014-10-30	Approved with change
201111-0938-009	No material or nonsubstantive change to a currently approved collection	2011-11-22	Approved without change
201109-0938-004	New collection (Request for a new OMB Control Number)	2011-09-19	Approved without change

OMB Details

Active GenICs (NOA issued 07-29-2026)

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form See NOA	GenICs Active as of 7-29-2026	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.