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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
#10: Section 1115 Demonstration and Waiver Application
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
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 (#10)
Benefit Specifications and Provider Qualifications
Benefit Specifications and Provider Qualifications.docx
Yes
Yes
Fillable Printable
Form
CMS-10398 (#10)
Budget Neutrality Form
Budget Neutrality Form_ 6 29 2012.docm
Yes
Yes
Fillable Printable
Form and Instruction
CMS-10398 (#10)
Demonstration Financing Form
Demo Financing Form.docm
Yes
Yes
Fillable Printable
Instruction
Information on Cost Sharing Requirements.docx
No
Paper Only
Form
CMS-10398 (#10)
Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2
Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx
Yes
Yes
Fillable Printable
Instruction
List of Eligibility Groups.docm
No
Paper Only
Form and Instruction
CMS-10398 (#10)
Long Term Services and Supports Form
List of LTSS Benefits.docm
Yes
Yes
Fillable Printable
Instruction
List of Medicaid and CHIP Benefits.docm
No
Paper Only
Instruction
List of Waivers and Expenditure Authorities_ 6 28 12.docm
No
Printable Only
Form
CMS-10398 (#10)
Long Term Services Benefit Specifications and Provider Qualifications
Long Term Services Benefit Specifications and Provider Qualifications.docx
Yes
Yes
Fillable Printable
Instruction
New Demo App Template [rev 07-11-2012 by OSORA PRA].docx
Yes
Yes
Fillable Printable
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)
2,240
0
2,240
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
#10 Supporting Statement: Section 1115 Demonstration and Waiver Application
#10 1115 Supporting Statement [Dec 2014].docx
12/22/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.