Information Collection

Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)

IC 208912 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⚠️ Notice: This information collection may be referencing outdated material.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 (#22) Bundle 3 GenICs - Health Home SPA (#22), Primary Care Payment Increase (#23), and Medicaid Accountability (#24)	Form
Medicaid Primary Care Payment Increase - State Data Collection Tool 8-20-13.xls	Instruction
I - ICFID instructions final.doc	Instruction
II - ICFID Guidance final.docx	Instruction
III - Clinic Instructions Final.doc	Instruction
IV - Clinic UPL Guidance final.docx	Instruction
V - ACR Narrative Instructions Final Draft Clean.docx	Instruction
VII - Other facility Instructions final.docx	Instruction
VIII - Other Facility Guidance -Final.docx	Instruction
CMS-10398 (#22) Health Home State Plan Amendment MMDLHealthHomesBlankTestState.pdf	Form
CMS-10398 (#22) Health Homes Administrative Component MMDLHealthHomesAdminReportBlankTestState.pdf	Form
CMS-10398 (#23) ACR Supplemental Payment Demonstration Guidance VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx	Form
CMS-10398 (#23) Funding Questions IX - Funding Questions.doc	Form
Health Home SPA Supporting Statement.docx Supporting Statement - Health Home (#22)	IC Document
Supporting Statement.docx Supporting Statement - Primary Care Payment Increase (#23)	IC Document
Medicaid Accountability UPL Part 2 Supporting Statement.docx Supporting Statement - Medicaid Accountability (#24)	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

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 %

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	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

table that charts IC Documents
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.