Information Collection

#10: Section 1115 Demonstration and Waiver Application

IC 214293 under ICR 201410-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Information on Cost Sharing Requirements.docx	Instruction
List of Eligibility Groups.docm	Instruction
List of Medicaid and CHIP Benefits.docm	Instruction
List of Waivers and Expenditure Authorities_ 6 28 12.docm	Instruction
New Demo App Template [rev 07-11-2012 by OSORA PRA].docx	Instruction
CMS-10398 (#10) Benefit Specifications and Provider Qualifications Benefit Specifications and Provider Qualifications.docx	Form
CMS-10398 (#10) Budget Neutrality Form Budget Neutrality Form_ 6 29 2012.docm	Form
CMS-10398 (#10) Demonstration Financing Form Demo Financing Form.docm	Form and Instruction
CMS-10398 (#10) Interim Section 1115 Demonstration Application Budget Ne 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 and Instruction
CMS-10398 (#10) Long Term Services Benefit Specifications and Provider Q Long Term Services Benefit Specifications and Provider Qualifications.docx	Form
#10 1115 Supporting Statement [Dec 2014].docx #10 Supporting Statement: Section 1115 Demonstration and Waiver Application	IC Document

IC Title:

#10: Section 1115 Demonstration 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			List of Medicaid and CHIP Benefits.docm	No		Paper Only
Instruction			List of Waivers and Expenditure Authorities_ 6 28 12.docm	No		Printable Only
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
Instruction			New Demo App Template [rev 07-11-2012 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form	CMS-10398 (#10)	Benefit Specifications and Provider Qualifications	Benefit Specifications and Provider Qualifications.docx	Yes	Yes	Fillable Printable
Instruction			Information on Cost Sharing Requirements.docx	No		Paper Only
Form	CMS-10398 (#10)	Interim Section 1115 Demonstration Application Budget Neutrality Table Shell, v2	Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx	Yes	Yes	Fillable Printable
Instruction			List of Eligibility Groups.docm	No		Paper Only
Form and Instruction	CMS-10398 (#10)	Long Term Services and Supports Form	List of LTSS Benefits.docm	Yes	Yes	Fillable Printable
Form	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

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#10 Supporting Statement: Section 1115 Demonstration and Waiver Application	#10 1115 Supporting Statement [Dec 2014].docx	12/22/2014

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