Information Collection

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

IC 229609 under ICR 201712-0938-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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 #10 Benefit Specifications and Provider Qualifications GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form
Form CMS-10398 #10 Budget Neutrality Form GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction
Form CMS-10398 #10 Demonstration Financing Form GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction
Form CMS-10398 #10 BN Table Shell GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form
Form CMS-10398 #10 Long Term Services and Supports Form GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form
Form CMS-10398 #10 Long Term Services Benefit Specifications and Provider Qualifications GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form
Form CMS-10398 #10 Section 1115 Demonstration Program Application Guide GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application	Form and Instruction
10 - Information on Cost Sharing Requirements.docx	Instruction
10 - List of Eligibility Groups.docm	Other-List of eligibility Groups
10 - List of Medicaid and CHIP Benefits.docm	Other-List of Medicaid and CHIP Bene
10 - List of Waivers and Expenditure Authorities_ 6 28 12.docm	Other-List of Frequently Requested W
CMS-10398 #10 Benefit Specifications and Provider Qualifications 10 - Benefit Specifications and Provider Qualifications.docx	Form
CMS-10398 #10 Budget Neutrality Form 10 - Budget Neutrality Form_ 6 29 2012.docm	Form and Instruction
CMS-10398 #10 Demonstration Financing Form 10 - Demo Financing Form.docm	Form and Instruction
CMS-10398 #10 BN Table Shell 10 - Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx	Form
CMS-10398 #10 Long Term Services and Supports Form 10 - List of LTSS Benefits.docm	Form
CMS-10398 #10 Long Term Services Benefit Specifications and Provider Q 10 - Long Term Services Benefit Specifications and Provider Qualifications.docx	Form
CMS-10398 #10 Section 1115 Demonstration Program Application Guide 10 - New Demo App Template [rev 07-11-2012 by OSORA PRA].docx	Form and Instruction
10 - Supporting Statement 1115 Demonstration and Application_11 16 17 rev.docx #0 - Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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
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

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: 5

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

Documents for IC

table that charts IC Documents
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.