Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium (CMS-10629)

Forms and Documents

Document Name	Status
Form CMS-10629 Waiver Application Form and Instruction	Modified
CMS-10629 - Supporting Statement for Enrollment Moratorium - Final 523.docx Supporting Statement A	2018-05-24

IC Document Collections

IC ID	Document Title	Status
222831	Waiver Application Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1313	ICR Reference No: 201703-0938-007
Status: Historical Active	Previous ICR Reference No: 201608-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium (CMS-10629)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/29/2018
	Date Received in OIRA: 03/07/2017
Terms of Clearance: Within six months, CMS shall provide to OMB its plan for evaluating this demonstration. Specifically, the evaluation plan shall clearly identify how CMS will document and test whether the heightened screening approach results in measurable reductions waste, fraud, and abuse. The plan shall be specific about how the information collected will be used in the evaluation, and include an evaluation design with appropriate rigor to assess the effectiveness of this demonstration.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved
Responses	800	0	0
Time Burden (Hours)	4,800	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Waiver Application demonstration will allow CMS to make individual exceptions to a state-wide moratorium due to access to care issues, which will allow enrollment of a provider or supplier after a heightened review of enrolling providers or suppliers.

---

Authorizing Statute(s): US Code: 42 USC 1395b-l(a)(1)(J) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: US Code: 42 USC 1395b-1(a)(1)(J) Name of Law: Social Security Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 75408	10/31/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 11037	02/17/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Waiver Application	CMS-10629	Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium

---

ICR Summary of Burden

	Total Approved	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	800	0	0	0	0	800
Annual Time Burden (Hours)	4,800	0	0	0	0	4,800
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/07/2017

---