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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicaid Premiums and Cost Sharing (#29)
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10398 (#29)
Medicaid Premiums and Cost Sharing
Copy of Medicaid Cost Sharing_FINAL_2-3-14_clean2.pdf
Yes
Yes
Fillable Printable
Instruction
IG_G1-Cost Sharing Requirements_Draft_MMDL_2-3-14(final clean).pdf
Yes
No
Printable Only
Instruction
IG_G2a_Cost Sharing Amounts-CN_Draft_MMDL_2-3-14(final clean).pdf
Yes
No
Printable Only
Instruction
IG_G2b_Cost Sharing Amounts-MN_Draft_MMDL_2-3-14(final clean).pdf
Yes
No
Printable Only
Instruction
IG_G2c-Cost Sharing Amounts-Targeting_Draft_2-3-14(final clean) (4).pdf
Yes
No
Printable Only
Instruction
IG_G3-Cost Sharing Limitations_Draft_MMDL_2-3-14(final clean) (3).pdf
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
10
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
10
0
0
0
0
0
Annual IC Time Burden (Hours)
50
0
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-10398 (#29) Supporting Statement
CMS-R-53 - Generic Supporting Statement [rev 3-18-2014 by OSORA PRA].docx
03/18/2014
Crosswalk
Cost Sharing Crosswalk 1 16 14 rys rb.pdf
03/18/2014
Summary of Comments/CMS Response
CMS R-53 Response to Comments to OMB (v2).doc
03/18/2014
NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint
NHeLP_Comments_to_CMS-R-53_Cost-Sharing_Preprint.pdf
03/18/2014
FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d
FINAL-TTAG_comments_CMS-R-53_CMS-10398_2014-03-17d.pdf
03/18/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.