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[Medicaid] GenIC #15 (Revision): Medicaid State Plan Eligibility CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction A1 Yes Yes Fillable Fileable
Form and Instruction A2 Yes Yes Fillable Fileable
Form and Instruction A3 Yes Yes Fillable Fileable
Form and Instruction A4 Yes Yes Fillable Fileable
Form and Instruction A5 Yes Yes Fillable Fileable
Form and Instruction I1 Yes Yes Fillable Fileable
Form and Instruction I2 Yes Yes Fillable Fileable
Form and Instruction I3 Yes Yes Fillable Fileable
Form and Instruction I4 Yes Yes Fillable Fileable
Form and Instruction I5 Yes Yes Fillable Fileable
Form and Instruction S2 Yes Yes Fillable Fileable
Form and Instruction S2T Yes Yes Fillable Fileable
Form and Instruction S3 Yes Yes Fillable Fileable
Form and Instruction S3A Yes Yes Fillable Fileable
Form and Instruction S4 Yes Yes Fillable Fileable
Form and Instruction S10 Yes Yes Fillable Fileable
Form and Instruction S10T Yes Yes Fillable Fileable
Form and Instruction S11 Yes Yes Fillable Fileable
Form and Instruction S11A Yes Yes Fillable Fileable
Form and Instruction S13A Yes Yes Fillable Fileable
Form and Instruction S14 Yes Yes Fillable Fileable
Form and Instruction S14A Yes Yes Fillable Fileable
Form and Instruction S14T Yes Yes Fillable Fileable
Form and Instruction S16 Yes Yes Fillable Fileable
Form and Instruction S17 Yes Yes Fillable Fileable
Form and Instruction S21 Yes Yes Fillable Fileable
Form and Instruction S25 Yes Yes Fillable Fileable
Form and Instruction S25A Yes Yes Fillable Fileable
Form and Instruction S28 Yes Yes Fillable Fileable
Form and Instruction S28A Yes Yes Fillable Fileable
Form and Instruction S28T Yes Yes Fillable Fileable
Form and Instruction S30 Yes Yes Fillable Fileable
Form and Instruction S30T Yes Yes Fillable Fileable
Form and Instruction S32 Yes Yes Fillable Fileable
Form and Instruction S32A Yes Yes Fillable Fileable
Form and Instruction S32T Yes Yes Fillable Fileable
Form and Instruction S33 Yes Yes Fillable Fileable
Form and Instruction S33A Yes Yes Fillable Fileable
Form and Instruction S50 Yes Yes Fillable Fileable
Form and Instruction S50A Yes Yes Fillable Fileable
Form and Instruction S51 Yes Yes Fillable Fileable
Form and Instruction S52 Yes Yes Fillable Fileable
Form and Instruction S53 Yes Yes Fillable Fileable
Form and Instruction S54 Yes Yes Fillable Fileable
Form and Instruction S55 Yes Yes Fillable Fileable
Form and Instruction S57 Yes Yes Fillable Fileable
Form and Instruction S59 Yes Yes Fillable Fileable
Form and Instruction S59A Yes Yes Fillable Fileable
Form and Instruction S88 Yes Yes Fillable Fileable
Form and Instruction S89 (revised) Yes Yes Fillable Fileable
Form and Instruction S94 Yes Yes Fillable Printable
Form and Instruction S94A Yes Yes Fillable Fileable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   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) 5 0 5 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement 06/09/2026
Crosswalk: S89 - Citizenship and Noncitizen Eligibility 06/08/2026
Response to Public Comments 06/08/2026
Public Comment (Anonymous) 06/08/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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