Form CMS-372(S) Annual Report on Home and Community-Based Services (HCBS

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Expiration Date: 11/3tJ/1024

1915(c_}

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372 Report Maintenance - Summary
State:
Waiver Base:
SUBMITTED

Report Status:
Begin Date:
End Date:
Initial Submission Date:
TE Date:
Report Period Year:
Waiver Year:

Year 1

Report Type:

Initial Report

Year 2

Year 3
Lag Report

Year 4

Year S

TE Report

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I, do certify that the information shown on the Form CMS-372(S} is correct to the best of my knowledge and belief:
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PRA Disclosure Statement

All State Medicaid agencies administering or supervising the administration of 1915(c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915(c)(2)
(E) of the Social Security Act requires states to annually provide CMS with information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the
Privacy Act of 1974 any personally identifying information obtained win be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time
required to complete this information collection is estimated to average 44 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, Maryland 21244-1850.

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Report Status:
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2018
Report Type:
Undupliuted P1 rticipan u:
Oa ys of Waiver ! nrollment;

Total Wa iYFile Typeapplication/pdfFile TitleWaiver Management System 372(S) Report ScreenshotsSubjectScreenshotsAuthorCMSFile Modified2024-05-10File Created2024-04-04