Electronic Visit Verification (EVV) Compliance Survey (CMS-10680)

Forms and Documents

Document Name	Status
Form CMS-10680 Electronic Visit Verification (EVV) Compliance Survey Form	New
EVV Crosswalk.docx Supplementary Document	2019-03-29
EVV Survey - Public Comment Response, March 2019.docx Supplementary Document	2019-03-29
CMS-10680 - Supporting Statement A (version 3).docx Supporting Statement A	2019-03-29
EVV Crosswalk.pdf Supplementary Document	2019-02-20
Electronic Visit Verification Compliance Survey - Public Comment Respons....pdf Supplementary Document	2019-02-20
CMS-10680 - Supporting Statement B (version 2).doc Supporting Statement B	2019-02-20

IC Document Collections

IC ID	Document Title	Status
235002	Electronic Visit Verification (EVV) Compliance Survey Form	New

ICR Details

OMB Control No: 0938-1360	ICR Reference No: 201902-0938-010
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Electronic Visit Verification (EVV) Compliance Survey (CMS-10680)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/10/2019
	Date Received in OIRA: 02/20/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	336	0	0
Time Burden (Hours)	504	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This collection entails an electronic, web-based survey that will allow states to self-report their progress in implementing electronic visit verification (EVV) for personal care services (PCS) and home health care services (HHCS), as required by section 1903(l) of the Social Security Act. The Center for Medicare and Medicaid Services (CMS) will use the survey data to assess states’ compliance with section 1903(l) of the Act and levy FMAP reductions where necessary as required by 1903(l) of the Act. Data collection will begin in November 2019 and will end when all states have fully implemented EVV systems according to the requirements specified at section 1903(l) of the Act.

---

Authorizing Statute(s): US Code: 42 USC 1903(l) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 50381	10/05/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 4073	02/14/2019
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Electronic Visit Verification (EVV) Compliance Survey	CMS-10680, CMS-10680	EVV Personal Care Services (PCS) Survey ,   EVV Home Health Care Services (HHCS) Survey

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	336	0	0	336	0	0
Annual Time Burden (Hours)	504	0	0	504	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There are no changes to the burden as this is a new information collection request.

---

Annual Cost to Federal Government: $163,966

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/20/2019

---