CMS-10628 State Moratoria Request Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-1328

INITIAL REQUEST FOR STATE IMPLEMENTED MORATORIUM
§ 455.470 requires that the State Medicaid agency must notify the Secretary in writing in the event the State
Medicaid agency seeks to impose a moratoria, including all details of the moratoria; and obtain the Secretary’s
concurrence with imposition of the moratoria.

1. ADMINISTRATIVE
State:

Agency:

Requester Name:

Title:

E-mail Address:

Telephone Number:

2. PROPOSED MORATORIUM
Provider/Supplier Type:

Provider/Supplier Type Subgroups:

Provider Implementation Date:

Upon CMS concurrence, the State Medicaid agency must impose the moratorium for an initial period of
6 months. If the State Medicaid agency determines that it is necessary, the State Medicaid agency may extend
the moratorium in 6-month increments. For each extension, the agency must document in writing the necessity
for extending the moratorium and obtain the Secretary’s concurrence.
If you intend the moratoria to be in place for longer than 6-months, what is the expected total length of time you expect the
moratoria to be necessary?
Geographical Area:
Entire State 

County Based  

Zip Code Based  

Other

List area included by county, zip code or other means, if not state based:

3. JUSTIFICATION FOR MORATORIUM
Provide the specific justification for the Moratorium:

Describe how proposed solutions will solve problem:

Describe previous efforts to solve problem:

Explain why a different tool wouldn’t be effective to solve this problem:

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4. MORATORIUM DATA
Describe the data that has been generated to support the following:
Need for Moratorium:

Moratorium will not create access to care issues:

5. EFFICACY
List and describe the metrics that will be used to determine whether the moratorium is effective:

6. ACCESS TO CARE
§ 455.470 requires that before implementing moratoria, caps, or other limits, the State Medicaid agency must
determine that its action would not adversely impact beneficiaries’ access to medical assistance.
Describe the ongoing review that will be done to identify potential access to care issues while the moratorium is in place:

Describe how access to care issues will be addressed:

7. ENFORCEMENT
Describe how you will direct your efforts during the moratorium to review existing providers and suppliers:

Will there be an appeals process for providers/suppliers who are removed from the system as a result of moratorium related
enforcement? If yes, describe below:

Is there any legal authority which allows for exceptions to the moratorium? If yes, include statute and describe the method of
implementation below:

What parameters do you have in place to ensure that exceptions to the moratorium are not arbitrary?

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8. EDUCATION AND OUTREACH
List the Entities with whom you will collaborate during the Moratorium implementation:
State Agencies:

Provider/Supplier Organizations:

Community:

9. CONTACT INFORMATION UPON IMPLEMENTATION OF MORATORIUM
Contact Person:

Name

Telephone Number

E-Mail Address

Moratorium Point of Contact:
Data Analyst:
Legal Analyst:
State Medicaid Director:

10. SIGNATURE
Signature Authority: The application must be signed by the State Medicaid Director.
Signature:

Printed Name:

Title:

Date:

11: SUBMISSION CHECKLIST
You must submit the following documentation to CMS for your request to be considered:
Completed Application
Access to Care Analysis and Summary
Note: If approved, quarterly submission of moratoria-related access to care analysis will be required for the
duration of the moratoria.

12. SUBMISSION INSTRUCTIONS
Please submit your completed application to: [email protected]
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1328.
The time required to complete this information collection is estimated to average 5 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. **CMS Disclaimer** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance
Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained.
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