View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0880
ICR Reference No:
202505-0938-014
Status:
Active
Previous ICR Reference No:
201702-0938-013
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMMI
Title:
Medicare/Medicaid Demonstration/Model Application (CMS-10069)
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
09/25/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/02/2025
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2028
36 Months From Approved
Responses
30
0
0
Time Burden (Hours)
2,400
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
This application provides an opportunity for States and organizations to apply for Medicare and Medicaid demonstrations/models. CMS seeks to test new demonstrations and models of care that aim to improve the quality of healthcare and lower healthcare costs through innovative approaches to service delivery and payment.
Authorizing Statute(s):
PL:
Pub.L. 92 - 603 402
Name of Law: Incentives for Economy While Maintaining or Improving Quality in the Provision of Health Services
US Code:
42 USC 1395B-1
Name of Law: Incentives for economy while maintaining or improving quality in provision of health services.
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
90 FR 2005
01/10/2025
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 22490
05/28/2025
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Medicare Waiver Demonstration Application
CMS-10069
Medicare Waiver Demonstration Ajpplication
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
30
0
0
-45
0
75
Annual Time Burden (Hours)
2,400
0
0
-3,600
0
6,000
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
This is a reinstatement of the previously approved collection. The burden has been revised and the wages used in our cost estimates have been updated to reflect the most recent BLS data. We have updated the annual burden hours specifically for the Rural Community Hospital Demonstration RFA. The annual burden hours decreased from 6,000 to 2,400.
Annual Cost to Federal Government:
$30,402
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Denise King 410 786-1013 Denise.King@cms.hhs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
06/02/2025
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