Medicare Waiver Demonstration Application

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
8706	Medicare Waiver Demonstration Application Form	Migrated

ICR Details

OMB Control No: 0938-0880	ICR Reference No: 200208-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Waiver Demonstration Application
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/04/2002
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/17/2002
	Date Received in OIRA: 08/22/2002
Terms of Clearance: This information collection request is approved consistent with the following terms of clearance: (1) this approval only covers the Physician Group Practice demonstration project and use of the standard application for the Capitated Disease Management, ESRD Disease Management and Population Centered Disease Management demonstration projects. (2) CMS will separately request OMB clearance under the PRA for each of the three disease management demonstration projects (3) For final OMB PRA approval for each of the disease management demonstrations, CMS will submit a brief cover memo identifying the item as one of the demonstration projects included in this package and explaining what the demo will do, who the respondents are, and what the burden is (4) CMS will also submit an 83-C that includes the OMB number for this package and contains all relevant information on respondents and burden (5) CMS will provide a copy of the application form(s) and a complete copy of the solicitation notice. (6) CMS will ensure that the OMB number, expiration date and PRA burden statement are displayed at the front of the application (7) As agreed, CMS understands that OMB approval of the standard application format for use with the three future disease management demonstrations listed does not imply OMB budget approval of the demonstration itself.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2003	03/31/2003
Responses	75	0	0
Time Burden (Hours)	1,600	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Waiver Demonstration Application will be used to collect standard information needed to implement Congressionally mandated and administration high priority demonstrations. The application will be used to gather information about the characteristics of the applicant's organization, benefits and services they propose to offer, success in operating the model, and evidence that the model is likely to be successful in the Medicare program. The standard application will be used for all waiver demonstrations and will reduce the burden on applicants, provide for consistent and timely information collections.......

Emergency Justfication:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Waiver Demonstration Application	CMS-10069

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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	75	0	0	75	0	0
Annual Time Burden (Hours)	1,600	0	0	1,600	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 08/22/2002

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