Survey Crosswalk (Changes to 30-day Pkg)

Electronic Visit Verification Compliance Survey
CMS-10680, OMB 0938-New
Crosswalk of Survey Changes
EVV PERSONAL CARE SERVICES SURVEY
Slides 43 – 48 were added with the new survey items below. The PRA disclosure statement on Slide 49
was updated to increase the time required to complete the survey from 100-120 minutes to 130-150
minutes.
 Slide 43: 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.
o [check box] Description of how the state ensured that its EVV system is minimally
burdensome. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)
o [check box] Not applicable. My state has not implemented EVV for any of the authorities
in the 21st Century Cures Act.
 Slide 44: 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 personal 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.
o [check box] Description of how the state took stakeholder process into account for EVV
design. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)
 Slide 45: 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 personal care services provider
selection (1500 character limit text box).
 Slide 46: 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 (1500 character limit text box).
 Slide 47: 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. (1500 character limit text box).
 Slide 48: 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).
o [check box] Description of how the state ensured the EVV system is in accordance with
HIPAA privacy and security law. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)
EVV HOME HEALTH CARE SERVICES SURVEY
Slides 33 – 38 were added with the new survey items below. The PRA disclosure statement on Slide 39
was updated to increase the time required to complete the survey from 100-120 minutes to 130-150

minutes.
 Slide 33: 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.
o [check box] Description of how the state ensured that its EVV system is minimally
burdensome. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)
o [check box] Not applicable. My state has not implemented EVV for any of the authorities
in the 21st Century Cures Act.
 Slide 34: 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.
o [check box] Description of how the state took stakeholder process into account for EVV
design. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)
 Slide 35: 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 (1500 character limit text box).
 Slide 36: 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 (1500 character limit text box).
 Slide 37: 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. (1500 character limit text box).
 Slide 38: 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).
o [check box] Description of how the state ensured the EVV system is in accordance with
HIPAA privacy and security law. (1500 character limit text box).
o [check box] Not applicable per Section 12006(a)(3) of the 21st Century Cures Act. My
state had an EVV system in place prior to the enactment of the 21st Century Cures Act.
(1500 character limit text box)