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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
CHIP Administration & Eligibility
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 430.12
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10434
CHIP Administration
CHIP Admin Form.pdf
Yes
Yes
Fillable Fileable
Instruction
IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CHIP Admin Introduction_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx
Yes
No
Printable Only
Instruction
IG_CS6 - Income Standards_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS16 - Spenddown_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx
Yes
No
Printable Only
Instruction
IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx
Yes
No
Printable Only
Form and Instruction
CMS-10434
CHIP Eligibility
CHIP Eligibility Form.pdf
Yes
Yes
Fillable Fileable
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:
56
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
56
0
56
0
0
0
Annual IC Time Burden (Hours)
1,568
0
1,568
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CHIP Administration - Webinar Transcript
CHIP Admin Webinar Transcript.pdf
01/08/2013
CHIP Eligibility - Webinar Transcript
CHIP Eligibility Transcript.pdf
01/09/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.