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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility
Agency IC Tracking Number:
CMCS
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 and Instruction
CMS-10434 #15
Designation and Authority
QSSI-MACPro-PRA-A1.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10434 #15
Intergovernmental Cooperation Act Waivers
QSSI-MACPro-PRA-A2.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10434 #15
Eligibility Determinations and Fair Hearings
QSSI-MACPro-PRA-A3.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10434 #15
Organization and Administration
QSSI-MACPro-PRA-A4.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Single State Agency Assurances
QSSI-MACPro-PRA-A5.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Submission Summary
QSSI-MACPro-PRA-I1.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Medicaid State Plan
QSSI-MACPro-PRA-I2.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Public Comment
QSSI-MACPro-PRA-I3.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Tribal Input
QSSI-MACPro-PRA-I4.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Other Comment
QSSI-MACPro-PRA-I5.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
MAGI Based Methodologies
QSSI-MACPro-PRA-S10.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
MAGI Based Methodologies – Territories
QSSI-MACPro-PRA-S10T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Reasonable Classification of Children All
QSSI-MACPro-PRA-S11.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Reasonable Classification of Children Limit
QSSI-MACPro-PRA-S11a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Income Standard
QSSI-MACPro-PRA-S13a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
AFDC Income Standards
QSSI-MACPro-PRA-S14.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Income Standards – Poverty Level – Territories
QSSI-MACPro-PRA-S14a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Income Standards - AFDC-related – Territories
QSSI-MACPro-PRA-S14T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Presumptive Eligibility for Children under Age 19
QSSI-MACPro-PRA-S16.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Qualified Entities
QSSI-MACPro-PRA-S17.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Financial Eligibility Requirements for Non-MAGI Groups
QSSI-MACPro-PRA-S2.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Presumptive Eligibility by Hospitals
QSSI-MACPro-PRA-S21.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Parents and Other Caretaker Relatives
QSSI-MACPro-PRA-S25.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Presumptive Eligibility for Parents and Other Caretaker Relatives
QSSI-MACPro-PRA-S25a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Pregnant Women
QSSI-MACPro-PRA-S28.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Presumptive Eligibility for Pregnant Women
QSSI-MACPro-PRA-S28a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Presumptive Eligibility for Pregnant Women
QSSI-MACPro-PRA-S28T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Financial Eligibility Requirements for Non-MAGI Groups – Territories
QSSI-MACPro-PRA-S2T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Optional Eligibility Groups
QSSI-MACPro-PRA-S3.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Infants and Children under Age 19
QSSI-MACPro-PRA-S30.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Infants and Children under Age 19 – Territories
QSSI-MACPro-PRA-S30T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Adult Group
QSSI-MACPro-PRA-S32.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Adult Group - Presumptive Eligibility
QSSI-MACPro-PRA-S32a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Adult Group - Presumptive Eligibility – Territories
QSSI-MACPro-PRA-S32T.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Former Foster Care Children
QSSI-MACPro-PRA-S33.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Former Foster Care Children – Presumptive Eligibility
QSSI-MACPro-PRA-S33a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
De-selected
QSSI-MACPro-PRA-S3a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Mandatory Eligibility Groups
QSSI-MACPro-PRA-S4.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Individuals above 133% FPL under Age 65
QSSI-MACPro-PRA-S50.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Individuals above 133% FPL under Age 65 - Presumptive Eligibility
QSSI-MACPro-PRA-S50a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Optional Coverage of Parents and Other Caretaker Relatives
QSSI-MACPro-PRA-S51.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Reasonable Classification of Individuals under Age 21
QSSI-MACPro-PRA-S52.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Children with Non IV-E Adoption Assistance
QSSI-MACPro-PRA-S53.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Optional Targeted Low Income Children
QSSI-MACPro-PRA-S54.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Individuals with Tuberculosis
QSSI-MACPro-PRA-S55.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Independent Foster Care Adolescents
QSSI-MACPro-PRA-S57.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Individuals Eligible for Family Planning Services
QSSI-MACPro-PRA-S59.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Individuals Eligible for Family Planning Services - Presumptive Eligibility
QSSI-MACPro-PRA-S59a.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
State Residency
QSSI-MACPro-PRA-S88.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Citizenship and Non-Citizenship
QSSI-MACPro-PRA-S89.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Eligibility Process
QSSI-MACPro-PRA-S94.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
1
Application
QSSI-MACPro-PRA-S94a.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)
1,120
0
1,120
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement
GenIC 15 - Supporting Statement (rev 06-28-2019 by OSORA PRA).docx
06/28/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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