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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
#17 (Revision): CHIP State Plan Eligibility
Agency IC Tracking Number:
CMCS
IC Status:
Unchanged
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
CMS-10398 #17
Eligibility for Medicaid Expansion Program
CS3.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Targeted Low-Income Children
CS7.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Targeted Low-Income Pregnant Women
CS8.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Coverage From Conception to Birth
CS9.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Children Who Have Access to Public Employee Coverage
CS10.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Pregnant Women Who Have Access to Public Employee Coverage
CS11.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Dental Only Supplemental Coverage
CS12.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Deemed Newborns
CS13.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
CS14.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
MAGI-Based Income Methodologies
CS15.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Other Eligibility Criteria – Spenddowns
CS16.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Eligibility – Residency
CS17.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Eligibility – Citizenship (Reinstatement)
CS18.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Eligibility - Social Security Number
CS19.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Eligibility - Substitution of Coverage
CS20.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Eligibility - Non-Payment of Premiums
CS21.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Requirements - Other Eligibility Standards
CS23.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
General Eligibility - Eligibility Processing
CS24.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
Non-Financial Requirements - Other Eligibility Standards (Revised)
CS27 - Revised.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
General Eligibility - Presumptive Eligibility for Children
CS28.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #17
General Eligibility - Presumptive Eligibility for Pregnant Women
CS29.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
0
0
0
56
Annual IC Time Burden (Hours)
5
0
0
0
0
5
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk: CS27 (Non-Financial Requirements - Other Eligibility Standards)
CS27 Crosswalk.xlsx
02/03/2022
#17 Generic Supporting Statement
17 - Generic Supporting Statement (2022 version 6).docx
02/03/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.