U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services MEDICARE WAIVER DEMONSTRATION APPLICATION DISCLOSURE STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0880. The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-10069 (12/2010) American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0880 MEDICARE WAIVER DEMONSTRATION APPLICANT DATA SHEET Applicant Legal Name Address City County Date Submitted Date Received by CMS State ZIP Code Name, telephone number and address of person to be contacted on matters involving the application. Descriptive Title of Applicant's Project Proposed Project From __________ To __________ Project Duration (mm/dd/yyyy) Type of Applicant Areas Affected by Project (cities, counties, states) o Academic Institution o Not for Profit Organization o Individual o Profit Organization o Other, please specify___________________________________ Applicant's Medicare Provider Number(s) Applicant's Employer Identification Number Is The Applicant a Medicare Provider/Organization in Good Standing? o Yes o No If "No," attach an explanation To the best of my knowledge and belief, all data in this application are true and correct, the document has been duly authorized by the governing body of the applicant and the applicant will comply with the terms and conditions of the award and applicable Federal requirements if awarded. Type Name and Title of Authorized Representative Signature of Authorized Representative Telephone Number (include area code) Date Signed (mm/dd/yyyy) Form CMS-10069 (12/2010) American LegalNet, Inc. www.FormsWorkFlow.com 2 MEDICARE WAIVER DEMONSTRATION APPLICATION This application provides an opportunity for eligible organizations to apply to participate in Medicare-waiver-only demonstrations sponsored by the Centers for Medicare & Medicaid Services (CMS). CMS conducts Medicare-waiver-only demonstrations to test innovations that have been shown to be successful in improving access and quality and/or lowering health care costs. These demonstrations may involve new benefits, fee-for-service or Medicare Advantage payment methodologies, and/or risk sharing arrangements that are not currently permitted under Medicare statute. Section 402 of Public Law 92-603 grants CMS the authority to waive Medicare payment and benefit statutes to conduct these demonstrations. Demonstrations may also be initiated as a result of Congressional mandate. BUDGET NEUTRALITY Medicare-waiver-only demonstrations must be budget neutral. Budget neutrality means that the expected costs under the demonstration cannot be more than the expected costs were the demonstration not to occur. Applicants must supply information and assumptions supporting budget neutrality that CMS will use in preparing a waiver package for submission to the President's Office of Management and Budget (OMB). OMB must approve Medicare waivers before implementing the demonstration. DUE DATE Applications will be considered timely if we receive on or before the due date specified in the "DATES" section of the demonstration solicitation. Applications must be received by 5 P.M EST/EDT on the due date. Only applications that are considered "timely" will be reviewed and considered by the technical review panel. APPLICATION SUBMISSION An unbound original and 2 copies plus an electronic copy on cd-rom must be submitted. Please note that applicants may, but are not required, submit 10 copies to assure that each review panel member receives the application in the manner intended by the applicant (e.g., collated, tabulated, color copies, etc.). The original and all copies, including the electronic copy, of the APPLICATION should be MAILED to the following address: Department of Health and Human Services, Centers for Medicare & Medicaid Services, ATTN: (Insert project officer name listed in demonstration solicitation and name of demonstration), Medicare Demonstrations Program Group, Office of Research, Development & Information, Mail Stop C4-17-27, 7500 Security Boulevard, Baltimore, Maryland, 21244. Applications must be typed for clarity in 12 point font and 1 inch margins and should not exceed 40 double-spaced pages, exclusive of the cover letter, executive summary, forms, and supporting documentation. Because of staffing and resource limitations, and because we require an application containing an original signature, we cannot accept applications by facsimile (FAX) transmission. FOR FURTHER INFORMATION Please contact the project officer listed in the demonstration solicitation and/or visit the CMS website at www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp#TopOfPage. Additional information about the demonstration, for example, fact sheets, design reports, solicitations, application materials, press releases, and question and answer documents will be periodically posted on the website. Be sure to check the website frequently if applying for a demonstration to be sure you have the most current information available. Form CMS-10069 (12/2010) American LegalNet, Inc. www.FormsWorkFlow.com 3 MEDICARE WAIVER DEMONSTRATION APPLICATION APPLICATION CONTENTS OUTLINE To facilitate the review process, applications should be arranged in the following order: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Cover Letter Medicare Waiver Demonstration Applicant Data Sheet Executive Summary Problem Statement Demonstration Design Organizational Structure & Capabilities Performance Results Payment Methodology & Budget Neutrality Demonstration Implementation Plan Supplemental Materials CMS may provide start-up funds to cover implementation costs associated with the demonstration. If start-up funding is available, it will be announced in the demonstration solicitation. If requesting start-up funds, please include th