OMB control number
Medicare/Medicaid Demonstration/Model Application (CMS-10069)
OMB 0938-0880 · HHS/CMS.
OMB 0938-0880
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 the quality of healthcare and lower healthcare costs through innovative approaches to service delivery and payment.
The latest form for Medicare/Medicaid Demonstration/Model Application (CMS-10069) expires 2028-09-30 and is listed under ICR 202505-0938-014.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10069 Medicare Waiver Demonstration Ajpplication | Form and Instruction |
| Form CMS-10069 Medicare Waiver Demonstration Application | Form and Instruction |
| PC_202505-0938-014_061125_124128_1.pdf | Public Comments |
 CMS-10069.Supporting Statement Part A 9-24-25 finalCLEAN.docx | Supporting Statement A |
| CMS-10069.Supporting Statement Part A (12-4-24).docx | Supporting Statement A |
 Medicare Waiver Demonstration Application |
Form and Instruction |
| Medicare Waiver Demonstration Application |
Form and Instruction |