Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180 and 441.300 - 441.310 (CMS-8003)

Forms and Documents

Document Name	Status
Form CMS-8003 Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310 Form and Instruction	Modified
CMS-8003 - Supporting Statement A (2020 version 4).docx Supporting Statement A	2020-09-24

IC Document Collections

IC ID	Document Title	Status
8072	Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0449	ICR Reference No: 202009-0938-008
Status: Active	Previous ICR Reference No: 201702-0938-023
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180 and 441.300 - 441.310 (CMS-8003)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/2020
	Date Received in OIRA: 09/25/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved
Responses	71	0	0
Time Burden (Hours)	6,005	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Under a Secretarial waiver, States may offer a wide array of home and community-based services to individuals who would otherwise require institutionalization. States requesting a waiver must provide certain assurances, documentation and cost & utilization estimates which are reviewed, approved and maintained for the purpose of identifying/verifying States' compliance with such statutory and regulatory requirements.

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Authorizing Statute(s): PL: Pub.L. 97 - 35 2176 Name of Law: Omnibus Budget Reconciliation Act (OBRA) of 1981
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 28010	05/12/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60169	09/24/2020
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310	CMS-8003	Application for a Section 1915(c) Home and Community-Based Services Waiver

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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	71	0	0	0	0	71
Annual Time Burden (Hours)	6,005	0	0	0	0	6,005
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:

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Annual Cost to Federal Government: $515,428

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.     No

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.     No

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? No

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Common Form ICR:  No

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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: 09/25/2020

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