Information Collection

[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide

IC 273876 under ICR 202409-0938-028 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Appendix B PACE AWOP & Rate Package Submission Cover Sheet [Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide	Form
PACE Medicaid Capitation Rate Setting Guide.pdf	Instruction
PACE Medicaid Capitation Rate Setting Guide_Appendix A.pdf	Instruction
PACE Medicaid Capitation Rate Setting Guide - AWOP Checklist FAQ .pdf	Instruction
Appendix B PACE AWOP & Rate Package Submission Cover Sheet PACE Medicaid Capitation Rate Setting Guide Appendix B (2024 version 3).pdf	Form
CMS response to comments received on #84 0938-1148.docx Response to Public Comments	IC Document
m4x-0t6n-rjb7 - Comment.pdf Comment (WelbeHealth)	IC Document
m4x-6hhp-7788 - Comment.pdf Comment (National PACE Association)	IC Document
GenIC 84 - Generic Supporting Statement (2024 version 11).docx Generic Supporting Statement	IC Document

IC Title:

[Medicaid] GenIC #84 (New): PACE Medicaid Capitation Rate Setting Guide

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Form	Appendix B	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

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	34	34
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Response to Public Comments		01/28/2025
Comment (WelbeHealth)		01/28/2025
Comment (National PACE Association)		01/28/2025
Generic Supporting Statement		01/28/2025

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

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