Information Collection

PACE State Plan Option Preprint (CMS-10227)

IC 181912 under ICR 202001-0938-017 · OMB 0938-1027.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.