Medicare/Medicaid Demonstration/Model Application (CMS-10069)

ICR 202505-0938-014

OMB: 0938-0880

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2025-06-02
IC Document Collections
ICR Details
0938-0880 202505-0938-014
Received in OIRA 201702-0938-013
HHS/CMS CMMI
Medicare/Medicaid Demonstration/Model Application (CMS-10069)
Reinstatement with change of a previously approved collection   No
Regular 06/02/2025
  Requested Previously Approved
36 Months From Approved
30 0
2,400 0
0 0

This application provides an opportunity for States and organizations to apply for Medicare and Medicaid demonstrations/models. CMS seeks to test new demonstrations and models of care that aim to improve health, lower costs through improvement, and provide better care for Medicare and Medicaid beneficiaries.

PL: Pub.L. 92 - 603 402 Name of Law: Incentives for Economy While Maintaining or Improving Quality in the Provision of Health Services
   US Code: 42 USC 1395B-1 Name of Law: Incentives for economy while maintaining or improving quality in provision of health services.
  
None

Not associated with rulemaking

  90 FR 2005 01/10/2025
90 FR 22490 05/28/2025
No

1
IC Title Form No. Form Name
Medicare Waiver Demonstration Application CMS-10069 Medicare Waiver Demonstration Ajpplication

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 30 0 0 -45 0 75
Annual Time Burden (Hours) 2,400 0 0 -3,600 0 6,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
This is a reinstatement of the previously approved collection. The burden has been revised and the wages used in our cost estimates have been updated to reflect the most recent BLS data. We have updated the annual burden hours specifically for the Rural Community Hospital Demonstration RFA. The annual burden hours decreased from 6,000 to 2,400.

$30,402
No
    No
    No
No
No
No
No
Denise King 410 786-1013 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/02/2025


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