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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
GenIC # 45 (Extension) - Maternal and Infant Health Quality
New
112
112
0
Form
CMS-10434 #45
Maternal and Infant Health
Other-PRA Disclosure Statement
GenIC #1 (Extension) - Initial Application
New
56
476
0
Form
CMS-10434 #1
Initial Application Combined
Form
CMS-10434 #1
Initial Application SPA Admin
Form
CMS-10434 #1
Initial Application
Other-PRA Disclosure Statement
GenIC #15 (Extension) - Medicaid State Plan Eligibility
New
56
1120
0
Form
CMS-10434 #15
Medicaid State Plan Eligibility
Other-PRA Disclosure Statement
GenIC #2 (Extension) - CHIP State Plan Eligibility
New
56
1568
0
Form
CMS-10434 #2
CHIP State Plan Eligibility
Other-PRA Disclosure Statement
GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)
New
30
2400
0
Form
CMS-10434 #22
Health Homes
Other-PRA Disclosure Statement
GenIC #26 (Extension) - Medicaid Adult and Child Core Set Measures
New
224
8960
0
Other-PRA Disclosure Statement
Form and Instruction
390-CQM 2018-CCW-CH-PRA-D
Contraceptive Care – All Women Ages 15-20 (CCW-CH)
Form and Instruction
385-CQM 2018-ADD-CH-PRA-D
CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
Form and Instruction
385-CQM 2018-ADD-CH-PRA-D
CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
Form and Instruction
429-AQM 2018 ABA-AD PRA-D
AQM 2018 – Adult Body Mass Index Assessment (ABA) Core Measure PRA document
Form and Instruction
245-QSSI-MACPro-PRA-AdditionalNotes-D
AQM, CQM & MIH - Additional Notes PRA document
GenIC #3 (Extension) - Alternative Benefit Plans (ABPs)
New
56
728
0
Form
CMS-10434 #3
ABP
Other-PRA Disclosure Statement
GenIC #47 (Extension) - Health Home Core Sets
New
30
1200
0
Form
CMS-10434 #47
Health Home Core Set
Other-PRA Disclosure Statement
GenIC #77 (New): Medicaid Extended Postpartum Coverage and Continuous Eligibility for Children
New
56
2548
0
Form and Instruction
CMS-10434 #77
Continuous Eligibility for Children (reviewable unit screenshots)
Form and Instruction
CMS-10434 #77
Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage (reviewable unit screenshots)
Form and Instruction
CMS-10434 #77
Home Page and Initial Application Forms
GenIC 22 (Revision): Health Home State Plan Amendment (SPA)
New
20
1600
0
Form
A1 - A5, HH1 - HH9, I1 - I5, and S (misc.)
1945 Health Home SPA Templates
Form
HH1A
1945A Health Homes Introduction
Form
HH2A
1945A Population and Enrollment
Form
HH3A
1945A Geographic Limitations
Form
HH4A
1945A Health Homes Services
Form
HH5A
1945A Health Homes Providers
Form
HH6A
1945A Health Homes Delivery Systems
Form
HH7A
1945A Health Homes Payment Methodologies
Form
HH8A
1945A Health Homes Monitoring, Quality Measurement, and Evaluation
Form
HH9A
1945A Health Homes Program Termination
Form
I2A
1945A Submission Summary
Form
I3A
1945A Public Comment
Form
I3aA
1945A Public Notice-Process
Form
I4A
1945A Tribal Input
Form
I5A
1945A Other Comment
Instruction
Instruction
Instruction
Instruction
Total Burden Actually Used for Information Collections Under Currently Approved ICR:
696
20712
0
Total Burden Currently Requested for Information Collections Under Currently Approved ICR:
0
0
0
To view an IC, click on IC Title