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Federal forms, ICRs, and supporting documents

Information Collection

Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)

IC 191978 under ICR 201002-0938-003 · OMB 0938-1084.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10300 Additional State Plan Option for Providing Premium Assistance CHIP Mediciad Template CMS-10300 XIX Template2 revised 3-4-10 per OMB.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10300 Additional State Plan Option for Providing Premium Assistance CHIP SPA Template CMS-10300 XXI Template1 revised 3-4-10.doc Yes Yes Fillable Fileable

Health Health Care Services

 

51 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 51 51 0 0 0 0
Annual IC Time Burden (Hours) 255 255 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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