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#15: Medicaid State Plan Eligibility
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 (#15) Medicaid Administration: State Plan Administration/ Designation and Authority A1-A3.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: MAGI-Based Income Methodologies S10.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: AFDC Income Standards S14.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Presumptive Eligibility by Hospitals S21.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives S25.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Pregnant Women S28.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19 S30.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Adult Group S32.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Mandatory Coverage Former Foster Care Children S33.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals above 133% FPL S50.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21 S52.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance S53.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children S54.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis S55.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents S57.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services S59.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility State Residency S88.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89.pdf Yes Yes Fillable Printable
Form CMS-10398 (#15) Medicaid Eligibility: General Eligibility Requirements Eligibility Process S94.pdf Yes Yes Fillable Printable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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) 1,120 0 1,120 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#15 Supporting Statement: Medicaid State Plan Eligibility #15 Medicaid State Plan Eligibility Supporting Statement [Dec 2014].docx 12/22/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.