PACE State Plan Option Preprint (CMS-10227)

PACE State Plan Amendment Pre-print (CMS-10227)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1027 can be found here:

Documents and Forms

Document Name Document Type
SMDL-11-09-00.tif Instruction
CMS-10227 PACE State Plan Amendment Pre-Print CMS-10227 SPA PACE PREPRINT (2020 version 3).rtf Form
Crosswalk PACE SPA Preprint Enclosure 7 (2020 version 3).xlsx Crosswalk - Preprint IC Document
CMS-10227 SPA PACE PREPRINT Redlined version (2020 version 3).rtf Track Change - Preprint IC Document

Information Collection (IC) Details

IC Title:	PACE State Plan Option Preprint (CMS-10227)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			SMDL-11-09-00.tif		No	No	Printable Only
Form	CMS-10227	PACE State Plan Amendment Pre-Print	CMS-10227 SPA PACE PREPRINT (2020 version 3).rtf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - Preprint	Crosswalk PACE SPA Preprint Enclosure 7 (2020 version 3).xlsx	05/18/2020
Track Change - Preprint	CMS-10227 SPA PACE PREPRINT Redlined version (2020 version 3).rtf	05/18/2020

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