Information Collection

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application

IC 203251 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
New Demo App Template [rev 07-11-2012 by OSORA PRA].docx	Instruction
Information on Cost Sharing Requirements.docx	Other-1115 Demo - Information on Cos
List of Eligibility Groups.docm	Other-1115 Demo - List of Medicaid E
List of Medicaid and CHIP Benefits.docm	Other-1115 Demo - List of Medicaid a
CMS-10398-009 Application for Section 1915(b)(4) Waiver - Fee For Serv 1915b(4) FFS preprint Template [rev 07-11-2012 by OSORA PRA].doc	Form and Instruction
CMS-10398-10 List of Frequently Requested Waivers and Expenditure Aut List of Waivers and Expenditure Authorities_ 6 28 12.docm	Form
CMS-10398-10 Benefit Specifications and Provider Qualifications Benefit Specifications and Provider Qualifications.docx	Form
CMS-10398-10 Long Term Services Benefit Specifications and Provider Q Long Term Services Benefit Specifications and Provider Qualifications.docx	Form
CMS-10398-10 Budget Neutrality Form Budget Neutrality Form_ 6 29 2012.docm	Form and Instruction
CMS-10398-10 Demonstration Financing Form Demo Financing Form.docm	Form and Instruction
CMS-10398-10 1115 Demonstration Application Budget Neutrality Table S Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx	Form
CMS-10398-10 Long Term Services and Supports Form List of LTSS Benefits.docm	Form
1115 Supporting Statement.docx Supporting Statement - 1115 Demonstration and Waiver Application	IC Document
1915b4 Supporting Statement.docx Supporting Statement - Application for Section 1915(b)(4) Waiver	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			New Demo App Template [rev 07-11-2012 by OSORA PRA].docx	Yes	No	Fillable Printable
Form and Instruction	CMS-10398-009	Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	1915b(4) FFS preprint Template [rev 07-11-2012 by OSORA PRA].doc	Yes	Yes	Fillable Printable
Form	CMS-10398-10	List of Frequently Requested Waivers and Expenditure Authorities	List of Waivers and Expenditure Authorities_ 6 28 12.docm	Yes	Yes	Fillable Printable
Other-1115 Demo - Information on Cost Sharing Requirements			Information on Cost Sharing Requirements.docx	Yes	No	Printable Only
Form	CMS-10398-10	Benefit Specifications and Provider Qualifications	Benefit Specifications and Provider Qualifications.docx	Yes	Yes	Fillable Printable
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
Form and Instruction	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
Other-1115 Demo - List of Medicaid Eligibility Groups			List of Eligibility Groups.docm	Yes	No	Fillable Printable
Other-1115 Demo - List of Medicaid and CHIP Benefits			List of Medicaid and CHIP Benefits.docm	Yes	No	Fillable Printable
Form	CMS-10398-10	1115 Demonstration Application Budget Neutrality Table Shell	Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398-10	Long Term Services and Supports Form	List of LTSS Benefits.docm	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 %

table that charts list of burden
	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	112	0	0	0	0	0
Annual IC Time Burden (Hours)	4,480	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - 1115 Demonstration and Waiver Application	1115 Supporting Statement.docx	07/11/2012
Supporting Statement - Application for Section 1915(b)(4) Waiver	1915b4 Supporting Statement.docx	07/11/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.