Information Collection

Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)

IC 222041 under ICR 201410-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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
42 - SPA Reimbursement Requirements Summary [rev 06-19-2016].docx	Instruction
47 - Health Homes Quality Measures Consolidated IG [rev 06-20-2016 by OSORA PRA].pdf	Instruction
CMS-10398 (#45) (Screen 1, Women) MIH Initiative Developmental Measure MIH_2015_by Women_1.pdf	Form
CMS-10398 (#45) (Screen 2, Women) MIH Initiative Developmental Measure MIH_2015_by Women_2.pdf	Form
CMS-10398 (#45) (Screen 3, Women) MIH Initiative Developmental Measure MIH_2015_by Women_3.pdf	Form
CMS-10398 (#45) (Screen 4, Women) MIH Initiative Developmental Measure MIH_2015_by Women_4.pdf	Form
CMS-10398 (#45) (Screen 5, Women) MIH Initiative Developmental Measure MIH_2015_by Women_5.pdf	Form
CMS-10398 (#45) (Screen 6, Women) MIH Initiative Developmental Measure MIH_2015_by Women_6.pdf	Form
CMS-10398 (#45) (Screen 1, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_1.pdf	Form
CMS-10398 (#45) (Screen 2, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_2.pdf	Form
CMS-10398 (#45) (Screen 3, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_3.pdf	Form
CMS-10398 (#45) (Screen 4, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_4.pdf	Form
CMS-10398 (#45) (Screen 5, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_5.pdf	Form
CMS-10398 (#45) (Screen 6, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_6.pdf	Form
CMS-10398 (#45) (Screen 7, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_7.pdf	Form
CMS-10398 (#45) (Screen 8, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_8.pdf	Form
CMS-10398 (#45) (Screen 9, Postpartum Women) MIH Initiative Developmenta MIH_2015_Postpartum Women_9.pdf	Form
CMS-10398 (#45) (Screen 10, Postpartum Women) MIH Initiative Development MIH_2015_Postpartum Women_10.pdf	Form
42 - Supporting Statement [rev 06-19-2016 by OSORA PRA].docx #42 - Supporting Statement (Covered Outpatient Drugs)	IC Document
45 - Maternal and Infant Health Quality Supporting Statement [rev 06-19-2016 by OSORA PRA].docx 45 - Supporting Statement (Maternal and Infant Health Quality)	IC Document
47 - Health Home Core Sets Supporting Statement [rev 06-19-2016 by OSORA PRA].docx 47 - Supporting Statement (Health Home Core Sets)	IC Document
Bundled Burden Table (06-20-2016).xlsx Bundled Burden Summary	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)

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
Instruction			42 - SPA Reimbursement Requirements Summary [rev 06-19-2016].docx	Yes	Yes	Printable Only
Form	CMS-10398 (#45)	(Screen 1, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_1.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 2, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_2.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 3, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_3.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 4, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_4.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 5, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_5.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 6, Women) MIH Initiative Developmental Measure	MIH_2015_by Women_6.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 1, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_1.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 2, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_2.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 3, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_3.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 4, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_4.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 5, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_5.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 6, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_6.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 7, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_7.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 8, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_8.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 9, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_9.pdf	Yes	Yes	Fillable Printable
Form	CMS-10398 (#45)	(Screen 10, Postpartum Women) MIH Initiative Developmental Measure	MIH_2015_Postpartum Women_10.pdf	Yes	Yes	Fillable Printable
Instruction			47 - Health Homes Quality Measures Consolidated IG [rev 06-20-2016 by OSORA PRA].pdf	Yes	Yes	Printable Only

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: 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 Agency Discretion
Annual Number of Responses for this IC	198	198
Annual IC Time Burden (Hours)	18,112	18,112
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#42 - Supporting Statement (Covered Outpatient Drugs)	42 - Supporting Statement [rev 06-19-2016 by OSORA PRA].docx	06/20/2016
45 - Supporting Statement (Maternal and Infant Health Quality)	45 - Maternal and Infant Health Quality Supporting Statement [rev 06-19-2016 by OSORA PRA].docx	06/20/2016
47 - Supporting Statement (Health Home Core Sets)	47 - Health Home Core Sets Supporting Statement [rev 06-19-2016 by OSORA PRA].docx	06/20/2016
Bundled Burden Summary	Bundled Burden Table (06-20-2016).xlsx	06/20/2016

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