CMS-10398-10 Benefit Specifications and Provider Qualifications

Benefit Specifications and Provider Qualifications

For each benefit or service that the State proposes to provide differently from that described in the State Plan, the State must complete this form by providing a description of the amount, duration and scope of the service under the Demonstration as well as the provider specifications and qualifications for the benefit or service.

Name of Benefit or Service:

Scope of Benefit/Service, including what is provided, what providers can provide the service, to whom it may be provided, how comprehensive the service is, and any other limitations on the benefit’s scope:

Amount of Benefit/Service – Describe any limitations on the amount of service provided under the Demonstration:

Benefit Amount: per Day Week Month Year

Other, describe:

Duration of Benefit/Service: Describe any limitations on the duration of the service under the demonstration:

	Day(s)
	Week(s)
	Month(s)
	(Other)

Authorization Requirements: Describe any prior, concurrent or post-authorization requirements, if any:

Provider Specifications and Qualifications

Provider Category(s):

Individual (list types) Agency (list types of agencies)

The service may be provided by a:

Legally Responsible Person Relative/Legal Guardian

Description of allowable providers:

Specify the types of providers of this benefit or service and their required qualifications:

1. Provider Type:

License Required: Yes No

Certificate Required: Yes No

Describe:

Other Qualifications Required for this Provider Type (please describe):

2. Provider Type:

License Required: Yes No

Certificate Required: Yes No

Describe:

Other Qualifications Required for this Provider Type (please describe):

3. Provider Type:

License Required: Yes No

Certificate Required: Yes No

Describe:

Other Qualifications Required for this Provider Type (please describe):

4. Provider Type:

License Required: Yes No

Certificate Required: Yes No

Describe:

Other Qualifications Required for this Provider Type (please describe):

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