Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.
Active GenICs (NOA issued 07-29-2026)	Modified	14559	231896	0	Form and Instruction	See NOA
GenIC #100 New (Medicaid Community Engagement: Good Faith Effort Exemptions and Quarterly Reporting)	Modified	18	380	0
GenIC #101 New (Medicaid Community Engagement: Short-term Hardship Exception Requests)	Modified	105300192	1208364	0
GenIC #11 Revised (MAGI-Based Eligibility Verification Plan)	Modified	156	5520	0	Form and Instruction	GenIC #11
					Form and Instruction	GenIC #11
					Form and Instruction	GenIC #11
GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Modified	2324	11352	0	Other-Performance Indicators Data Dictionary
	Modified	2324	11352	0	Form and Instruction	GenIC #35
GenIC #66 Revised (Eligibility Processing Data Report)	Modified	2388	8872	0	Form and Instruction	GenIC #66
					Other-Eligibility Processing Data Report Specifications
					Other-Data Report Instrument Metrics
					Other-SHO# 24-002
					Form and Instruction	GenIC #66
					Form and Instruction	GenIC #66
[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility	Modified	97	820	0	Form	CS3
					Form	CS7
					Form	CS8
					Form	CS9
					Form	CS10
					Form	CS11
					Form	CS12
					Form	CS13
					Form	CS14
					Form	CS15
					Form	CS16
					Form	CS17
					Form	CS18
					Form	CS19
					Form	CS20
					Form	CS21
					Form	CS22
					Form	CS23
					Form	CS24
					Form	CS27
					Form	CS28
					Form	CS29
					Form	CS31
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[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Modified	82	168	0	Form and Instruction	GenIC #34
[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Modified	30	5	0	Form and Instruction	CMS-10398 #34
[Medicaid] GenIC #99 (New): Medicaid Certified Community Behavioral Health Clinic (CCBHC) Services State Plan Amendment Coverage Template	Modified	56	280	0	Form and Instruction	GenIC #99
Total burden requested under this ICR:		105319902	1467657	0
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