Information Collection

#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412)

IC 214375 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10398 (#38) (f #38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412)	Form and Instruction
CMS-10398 (#38) (f Section 1115 Demonstration, Long Term Services and Suppo 2015 Medicaid Managed Care Rate Guidance 09-3-14.pdf	Form and Instruction
#38 Supporting Statement Section 1115 Demonstration Long Term Services [Dec 2014].docx #38 Supporting Statement: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disa	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

#38: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions (CMS-10412)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 (#38) (formerly, CMS-10412)	Section 1115 Demonstration, Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions	2015 Medicaid Managed Care Rate Guidance 09-3-14.pdf		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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	448	448
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#38 Supporting Statement: Section 1115 Demonstration: Long Term Services and Supports and Other Models for Individuals with Disabilities and Chronic Conditions	#38 Supporting Statement Section 1115 Demonstration Long Term Services [Dec 2014].docx	12/22/2014

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