Information Collection

Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments

IC 204808 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #11 Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments	Form and Instruction
CMS-10398 #11 MAGI-based Eligibility Verification Plan Verification_Plan_Template.docx	Form and Instruction
CMS-10398 #12 Reimbursement Template - Physician Services (Attachment Combined Primary Care Bump and VFC SPA Template.docx	Form
MAGI-Based Eligibility Verification Plan Supporting Statement.docx Supporting Statement - MAGI #11	IC Document
Supporting Statement Increase in Primary Care Services Payments [rev 11-08-2012 by OSORA PRA].docx Supporting Statement - Increase Primary Care Services Payments #12	IC Document

IC Title:

Bundle: (GenIC 1) MAGI-based Eligibility Verification Plan and (GenIC 2) Increase in Primary Care Services Payments

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 447.410

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #11	MAGI-based Eligibility Verification Plan	Verification_Plan_Template.docx		Yes	Yes	Fillable Printable
Form	CMS-10398 #12	Reimbursement Template - Physician Services (Attachment 4.19-B)	Combined Primary Care Bump and VFC SPA Template.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	107	0	0	0	0	0
Annual IC Time Burden (Hours)	4,688	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - MAGI #11	MAGI-Based Eligibility Verification Plan Supporting Statement.docx	11/08/2012
Supporting Statement - Increase Primary Care Services Payments #12	Supporting Statement Increase in Primary Care Services Payments [rev 11-08-2012 by OSORA PRA].docx	11/08/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.