Initial Request for State Implemented Moratorium Form (CMS-10628)

Congress has enacted section 1866 (j)(7) of the Social Security Act, which allows for the imposition of temporary moratorium. CMS promulgated 42 CFR 424.570 in order to comply with that statute, which requires that prior to implementing state Medicaid moratoria the state Medicaid agency must notify the Secretary in writing , including all of the details of the moratoria, and obtain the Secretary’s concurrence with the imposition of the moratoria. The “Initial Request for State Medicaid Implemented Moratorium” has been created to collect that data, in a uniform manner, which the states report to CMS when they request a moratorium.

The latest form for Initial Request for State Implemented Moratorium Form (CMS-10628) expires 2029-06-30 and is listed under ICR 202604-0938-002.