Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #15 (Extension w/o change): Medicaid State Plan Eligibility
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
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-10398 #15
Tab A1-A3 - Medicaid Administration: State Plan Administration/ Designation and Authority
A1-A3 (1).pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S10 – Medicaid Eligibility: MAGI-Based Income Methodologies
S10.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S14 – Medicaid Eligibility: AFDC Income Standards
S14.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S21 – Medicaid Eligibility: Presumptive Eligibility by Hospitals
S21.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S25 – Medicaid Eligibility: Mandatory Coverage Parents and Other Caretaker Relatives
S25.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S28 – Medicaid Eligibility: Mandatory Coverage Pregnant Women
S28.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S30 – Medicaid Eligibility: Mandatory Coverage Infants and Children under Age 19
S30.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S32 – Medicaid Eligibility: Mandatory Coverage Adult Group
S32.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S33 – Medicaid Eligibility: Mandatory Coverage Former Foster Care Children
S33.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S50 – Medicaid Eligibility: Options for Coverage Individuals above 133% FPL
S50.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S51 – Medicaid Eligibility: Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives
S51.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S52 – Medicaid Eligibility: Options for Coverage Reasonable Classification of Individuals under Age 21
S52.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S53 – Medicaid Eligibility: Options for Coverage Children with Non IV-E Adoption Assistance
S53.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S54 – Medicaid Eligibility: Options for Coverage Optional Targeted Low Income Children
S54.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S55 – Medicaid Eligibility: Options for Coverage Individuals with Tuberculosis
S55.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S57 – Medicaid Eligibility: Options for Coverage Independent Foster Care Adolescents
S57.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S59 – Medicaid Eligibility: Options for Coverage Individuals Eligible for Family Planning Services
S59.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S88 – Medicaid Eligibility: Non-Financial Eligibility State Residency
S88.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S89 – Medicaid Eligibility: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility
S89.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #15
Tab S94 – Medicaid Eligibility: General Eligibility Requirements Eligibility Process
S94.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 %
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
Documents for IC
Title
Document
Date Uploaded
#15 - Supporting Statement
15 - Final Supporting Statement Medicaid State Plan Eligibility.docx
12/29/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.