CMS-10680 EVV Home Health Care Services (HHCS) Survey

Electronic Visit Verification
(EVV) Home Health Care
Services (HHCS) Survey

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons
are required to respond to a collection of information unless it displays a valid OMB control
number. The Valid OMB control number for this information collection is 0938-1360 (Expires:
September 30, 2025). This information collection is mandatory for states to complete in order
to demonstrate compliance with section 1903(l) of the Social Security Act. States that are
otherwise fully compliant with the requirements may experience Federal Medical Assistance
Percentage (FMAP) reductions per section 1903(l)(1) of the Social Security Act if they do not
complete this information collection. Under the Privacy Act of 1974 any personally identifying
information obtained will be kept private to the extent of the law. The time required to complete
the information collection is estimated to average 13-150 minutes, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Office, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

EVV HHCS Survey
State:
Submitted on:

Please select the answer that best applies to your State's current EVV implementation status
for Authorities 1905(a)(7), 1915(c), 1915(i), and 1115 Demonstration for Home Health Care
Services (HHCS). My State has implemented EVV for _______________ authorities within
my State specified in 21st century Cures Act.
All
Some
Zero (none)
Has your State submitted an Advance Planning Document (APD)?
Yes
No
Has the APD been approved?
Yes
No
Please indicate the approval date of the APD.

Please indicate the CMS certification date of the EVV System.

Is EVV implemented for Authority 1905(a)(7)?
Yes - My State has implemented EVV for this Authority.
No - My State delivers HHCS under this authority and is required to become compliant
with the 21st Century Cures Act
N/A - My State does not have a waiver with this authority that includes HHCS and
therefore does not need to address this section.
Please indicate the implementation date for Authority 1905(a)(7).

Please select your State's EVV model for Authority 1905(a)(7). Select more than one if
necessary.
-

Open Vendor
State Mandated External Vendor
State Mandated Internal Vendor
Provider Choice
MCO Choice
Other

Is EVV implemented for Authority 1915(c)?
-

Yes - My State has implemented EVV for this Authority.
No - My State delivers HHCS under this authority and is required to become
compliant with the 21st Century Cures Act.
N/A - My State does not have a waiver with this authority that includes HHCS and
therefore does not need to address this section.

Please indicate the implementation date for Authority 1915(c).

Please select your State's EVV model for Authority 1915(c). Select more than one if
necessary.
-

Open Vendor
State Mandated External Vendor
State Mandated Internal Vendor
Provider Choice
MCO Choice
Other

Is EVV implemented for Authority 1915(i)?
-

Yes - My State has implemented EVV for this Authority.
No - My State delivers HHCS under this authority and is required to become
compliant with the 21st Century Cures Act.
N/A - My State does not have a waiver with this authority that includes HHCS and
therefore does not need to address this section.

Please indicate the implementation date for Authority 1915(i).

Please select your State's EVV model for Authority 1915(i). Select more than one
if necessary.
-

Open Vendor
State Mandated External Vendor
State Mandated Internal Vendor
Provider Choice
MCO Choice
Other

Is EVV implemented for Authority 1115 Demonstration?
-

Yes - My State has implemented EVV for this Authority.
No - My State delivers HHCS under this authority and is required to become
compliant with the 21st Century Cures Act.
N/A - My State does not have a waiver with this authority that includes HHCS and
therefore does not need to address this section.

Please indicate the implementation date for Authority 1115 Demonstration.

Please select your State's EVV model for Authority 1115 Demonstration. Select
more than one if necessary.
-

Open Vendor
State Mandated External Vendor
State Mandated Internal Vendor
Provider Choice
MCO Choice
Other

Is EVV implemented for another Authority that has not yet been listed?
-

Yes - My State has implemented EVV for this Authority.
No - My State delivers HHCS under this authority and is required to become
compliant with the 21st Century Cures Act.
N/A - My State does not have a waiver with this authority that includes HHCS and
therefore does not need to address this section.

Please provide a brief description of your State's EVV system.

Pursuant to Section 12006(a)(2)(A)(i), of the 21st Century Cures Act, please describe
how the state has ensured that its EVV system is minimally burdensome. Description of
how the state ensured that its EVV system is minimally burdensome. Description of how
the state ensured that its EVV system is minimally burdensome.

Pursuant to Section 12006(a)(2)(B) of the 21st Century Cures Act, please describe how
your state took into account a stakeholder process that included input from beneficiaries,
family caregivers, individuals who furnish home health care services, and other
stakeholders when designing its EVV system. Please note that the statute does not
require states that had a compliant EVV system in place prior to enactment of the 21st
Century Cures Act to seek stakeholder input and they therefore will not be required to
answer this question. Description of how the state took stakeholder process into account
for EVV design.

Pursuant to Section 12006(c)(3) of the 21st Century Cures Act, please describe how
your state has ensured that its EVV system does not limit home health care services
provider selection.

Pursuant to Section 12006(c)(3) of the 21st Century Cures Act, please describe how your
state has ensured that its EVV system does not constrain beneficiaries’ selection of a
caregiver.

Pursuant to Section 12006(c)(3) of the 21st Century Cures Act, please describe how your
state has ensured that its EVV system does not impede the manner in which care is
delivered.

Pursuant to Section 12006(a)(2)(A)(iii) of the 21st Century Cures Act, please describe
how the state has ensured that the EVV system is conducted in accordance with the
requirements of HIPAA privacy and security law (as defined in section 3009 of the
Public Health Service Act). Description of how the state ensured the EVV system is in
accordance with HIPAA privacy and security law requirements.