CMS-10398 #75 Template for Medicaid Section 1135 Waiver of SPA Submiss

Medicaid Section 1135 Waiver of SPA Submission Requirements Template

A state or territory may request a Section 1135 SPA process waiver(s) if the President has declared a major disaster or an emergency under the Stafford Act, or an emergency under the National Emergencies Act, and the Secretary of the Department of Health and Human Services has declared a public health emergency.  The Centers for Medicare and Medicaid Services (CMS) will review the state’s request to determine whether the section 1135 waiver request will help the state or territory ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the Medicaid program.  

 

Note: State Medicaid Agencies must request separate section 1135 waiver authority for each Emergency Relief SPA submitted.  Agencies may not request section 1135 waiver authority for a SPA that includes any changes that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers.  

 

State: <text field: insert State>

SPA Number: <text field: insert SPA number>

The agency seeks the following under section 1135(b)(5) of the Social Security Act (check all that apply): 

☐ Submission Deadlines: Pursuant to section 1135 (b)(5) of the Act, allows modification of the requirement to submit the SPA by the last day of a quarter, in order to obtain a SPA effective date during that quarter (applicable only for quarters in which the emergency or disaster declaration is in effect) - 42 C.F.R. § 430.20

☐ Public notice requirements: Pursuant to section 1135 (b)(5) of the Act, allows a modification of public notice requirements that would otherwise be applicable to SPA submissions.  These requirements may include those specified in 42 C.F.R. § 440.386 (Alternative Benefit Plans), 42 C.F.R. § 447.57(c) (premiums and cost sharing), and 42 C.F.R. § 447.205 (public notice of changes in statewide methods and standards for setting payment rates). Requested modifications are as follows:

☐ Tribal Consultation: Pursuant to section 1135 (b)(5) of the Act, allows modification of the required Tribal consultation timelines specified in the Medicaid state plan per section 1902(a)(73) of the Act. Requested modifications are as follows:

PRA Disclosure Statement Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 75). Public burden for all of the collection of information requirements under this control number is estimated to take up to 1 hour per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.