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Federal forms, ICRs, and supporting documents

Information Collection

#10: Section 1115 Demonstration and Waiver Application

IC 214293 under ICR 201410-0938-016 · OMB 0938-1148.

Documents and Forms
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Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Form and Instruction
Form
Form and Instruction
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IC Document
Information Collection (IC) Details

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#10: Section 1115 Demonstration 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 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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 56 0 56 0 0 0
Annual IC Time Burden (Hours) 2,240 0 2,240 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.