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

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.