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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #2 - CHIP State Plan Eligibility
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-10434 (#2)
CHIP Admin
GenIC #2 Screen Shots - CHIP Admin.pdf
Yes
Yes
Fillable Printable
Form
CMS-10434 (#2)
CHIP Eligibility
GenIC #2 Screen Shots - CHIP Eligibility.pdf
Yes
Yes
Fillable Printable
Instruction
#2 - IG_CA1 - Program Type Designation_R1_Final_ 11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CA2 - Designation and Authority_R1_Final_11-30-12.docx
Yes
Yes
Printable Only
Instruction
#2 - IG_CA3- Organization and Administation_R1_Final_ 11-30-12.docx
Yes
Yes
Printable Only
Instruction
#2 - IG_CA4 - CHIP State Plan Administration-Assurances_R1_Draft_11-30-12.docx
Yes
Yes
Printable Only
Instruction
#2 - IG_CHIP Admin Introduction_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CHIP Eligibility Introduction_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS3 - Medicaid Expansion_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS4 - Separate CHIP Covered Groups_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS5 - Completion of Covered Groups_R1_Final_11-30-12 .docx
No
Printable Only
Instruction
#2 - IG_CS6 - Income Standards_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS7 - Targeted Low-Income Child_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS8 - Targeted Low-Income Pregnant Women_R1_Final_ 11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS9 - Coverage from Conception to Birth_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS10- Children with Access to Public Employee Coverage_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS11 - Pregnant Women Who Have Access to Public Employee Coverage_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS12 - Dental Only Supplemental Coverage_R1_Final_ 11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS13 - Deemed Newborns_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS14 - Children Inelig for Medicaid as a Result of the Elim of Income Disregards_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS15 - MAGI-Based Income Methodologies_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS16 - Spenddown_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS17 - Non-Financial-Residency_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS18 - Non-Financial-Citizenship_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS19 - Non-Financial-Social Security Number_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS20 - Non-Financial-Substitution of Coverage_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS21 - Non-Financial-Non-Payment of Premiums_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS22 - Non-Financial Requirements_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS23 - Non-Financial Requirement-Other Eligibility Standards_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS24 - Eligibility Processing_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS25 - Beginning Date of Eligibility_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS26 - Ending Dates of Eligibility_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS27 - Continuous Eligibility_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS28 - Presumptive Eligibility for Children_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS29 - Presumptive Eligibility for Pregnant Women_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS30 - Qualified Entities_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS32 - Express Lane Eligibility_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS33 - Express Lane Agencies_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#2 - IG_CS34 - Express Lane Eligibility Components_R1_Final_11-30-12.docx
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:
56
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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)
1,568
0
1,568
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
GenIC #2 - Supporting Statement (CHIP State Plan Eligibility)
GenIC # 2 - Supporting Statement CHIP Templates [rev 03-28-2016 by OSORA PRA].docx
03/30/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.