OMB.report

Federal forms, ICRs, and supporting documents

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.

Documents and Forms
Document Name
Document Type
Instruction
Other-1115 Demo - Information on Cos
Other-1115 Demo - List of Medicaid E
Other-1115 Demo - List of Medicaid a
Form and Instruction
Form
Form
Form
Form and Instruction
Form and Instruction
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  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

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.