Form CMS-10628 State Moratoria Request Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services OMB No. 0938-NEW Expires: xx/xxxx

INITIAL REQUEST FOR STATE IMPLEMENTED MORATORIUM

§ 455.470 requires that the State Medicaid agency must notify the Secretary in writing in the event the State Medicaid agency seeks to impose a moratoria, including all details of the moratoria; and obtain the Secretary’s concurrence with imposition of

Describe previous efforts to solve problem:

Explain why a different tool wouldn’t be effective to solve this problem:

INITIAL REQUEST FOR STATE IMPLEMENTED MORATORIUM

PART IV. MORATORIUM DATA

Describe the data that has been generated to support the following:

Need for Moratorium:

implementation below:

What parameters do you have in place to ensure that exceptions to the moratorium are not arbitrary?

INITIAL REQUEST FOR STATE IMPLEMENTED MORATORIUM

PART VIII. EDUCATION AND OUTREACH

List the Entities with whom you will collaborate during the Moratorium implementation:

State Agencies:

OR

Division of Enrollment Operations, Moratoria Submission

Centers for Medicare & Medicaid Services

Provider Enrollment and Oversight Group

7500 Security Boulevard, Mail Stop AR-19-51

Baltimore, Maryland 21244-1850

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