Information Collection

GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook

IC 231323 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⚠️ Notice: This information collection may be referencing outdated material.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 #56 GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook	Form
Playbook-SU-Budget Neutrality-1115PMDA-20180420-v1.3.docx	Instruction
Script Completing a BNW SU version 1.3.docx	Instruction
Video - Budget Neutrality Workbook Template.docx	Instruction
CMS-10398 #56 PMDA Budget Neutrality Workbook Template Copy of BN Template -1115 PMDA-20180425 v2.5.xlsm	Form
CMS 1115 Budget Neutrality Workbook - Supporting Statement (rev 05-03-2018 at 0845 am by OSORA PRA).docx Supporting Statement: Budget Neutrality Workbook	IC Document

IC Title:

GenIC #56 (New): Section 1115 Demonstration: Budget Neutrality Workbook

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Voluntary

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 #56	PMDA Budget Neutrality Workbook Template	Copy of BN Template -1115 PMDA-20180425 v2.5.xlsm	Yes	Yes	Fillable Fileable
Instruction			Playbook-SU-Budget Neutrality-1115PMDA-20180420-v1.3.docx	Yes	No	Fillable Fileable
Instruction			Script Completing a BNW SU version 1.3.docx	Yes	No	Fillable Fileable
Instruction			Video - Budget Neutrality Workbook Template.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	307	307
Annual IC Time Burden (Hours)	1,897	1,897
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement: Budget Neutrality Workbook	CMS 1115 Budget Neutrality Workbook - Supporting Statement (rev 05-03-2018 at 0845 am by OSORA PRA).docx	05/03/2018

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