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Federal forms, ICRs, and supporting documents

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.

Documents and Forms
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Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
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Form
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IC Document
IC Document
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Information Collection (IC) Details

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

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

Health Health Care Services

 

52 0
   
State, Local, and Tribal Governments
 
   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

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.