Information Collection

Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (Annual - effective 1/1/2012)

IC 195885 under ICR 201912-0938-008 · OMB 0938-1127.

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Information Collection (IC) Details

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IC Title:	Elimination of Cost-Sharing for full benefit dual-eligible Individuals Receiving Home and Community-Based Services (Annual - effective 1/1/2012)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.772 42 CFR 423.782

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	612	612
Annual IC Cost Burden (Dollars)	0	0

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