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GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application

IC 229609 under ICR 201712-0938-019 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Form
Instruction
Other-List of eligibility Groups
Other-List of Medicaid and CHIP Bene
Other-List of Frequently Requested W
Form
Form and Instruction
Form and Instruction
Form
Form
Form
Form and Instruction
IC Document
Information Collection (IC) Details

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GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 #10 Benefit Specifications and Provider Qualifications 10 - Benefit Specifications and Provider Qualifications.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #10 Budget Neutrality Form 10 - Budget Neutrality Form_ 6 29 2012.docm Yes Yes Fillable Fileable
Instruction 10 - Information on Cost Sharing Requirements.docx No   Printable Only
Form CMS-10398 #10 BN Table Shell 10 - Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #10 Demonstration Financing Form 10 - Demo Financing Form.docm Yes Yes Fillable Fileable
Other-List of eligibility Groups 10 - List of Eligibility Groups.docm No   Printable Only
Form CMS-10398 #10 Long Term Services and Supports Form 10 - List of LTSS Benefits.docm Yes Yes Fillable Fileable
Other-List of Medicaid and CHIP Benefits 10 - List of Medicaid and CHIP Benefits.docm No   Printable Only
Other-List of Frequently Requested Waivers and Expenditure Authorities 10 - 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 10 - Long Term Services Benefit Specifications and Provider Qualifications.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #10 Section 1115 Demonstration Program Application Guide 10 - New Demo App Template [rev 07-11-2012 by OSORA PRA].docx Yes Yes Fillable Fileable

Health Health Care Services

 

5 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 5 0 5 0 0 0
Annual IC Time Burden (Hours) 1,600 0 1,600 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#0 - Supporting Statement 10 - Supporting Statement 1115 Demonstration and Application_11 16 17 rev.docx 12/29/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.