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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10398 (#22)
Health Home State Plan Amendment
MMDLHealthHomesBlankTestState.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#22)
Health Homes Administrative Component
MMDLHealthHomesAdminReportBlankTestState.pdf
Yes
Yes
Fillable Printable
Instruction
Medicaid Primary Care Payment Increase - State Data Collection Tool 8-20-13.xls
Yes
Yes
Fillable Printable
Instruction
I - ICFID instructions final.doc
Yes
No
Printable Only
Instruction
II - ICFID Guidance final.docx
Yes
No
Printable Only
Instruction
III - Clinic Instructions Final.doc
Yes
No
Printable Only
Instruction
IV - Clinic UPL Guidance final.docx
Yes
No
Printable Only
Instruction
V - ACR Narrative Instructions Final Draft Clean.docx
Yes
No
Printable Only
Form
CMS-10398 (#23)
ACR Supplemental Payment Demonstration Guidance
VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx
Yes
Yes
Fillable Printable
Instruction
VII - Other facility Instructions final.docx
Yes
No
Printable Only
Instruction
VIII - Other Facility Guidance -Final.docx
Yes
No
Printable Only
Form
CMS-10398 (#23)
Funding Questions
IX - Funding Questions.doc
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
52
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
160
0
0
0
0
0
Annual IC Time Burden (Hours)
6,720
0
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement - Health Home (#22)
Health Home SPA Supporting Statement.docx
09/30/2013
Supporting Statement - Primary Care Payment Increase (#23)
Supporting Statement.docx
09/30/2013
Supporting Statement - Medicaid Accountability (#24)
Medicaid Accountability UPL Part 2 Supporting Statement.docx
09/30/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.