Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2023 Renewal: Extension without change of active collections of information (GenICs #1, #2, #3, #15, #22, #26, #45, #47, and #77) New 696 20712 0 Other-Active GenICs Forms and Supplemental Documents
GenIC #22 (Revision): Health Home State Plan Amendment (SPA) New 18 54 0 Form CMS-10434 #22 1945 SPA Templates
Form CMS-10434 #22 HH8 – 1945 Health Homes Monitoring, Quality Measurement, and Evaluation
Form CMS-10434 #22 HH1A – 1945A Health Homes Introduction
Form CMS-10434 #22 HH2A – 1945A Population and Enrollment
Form CMS-10434 #22 HH3A – 1945A Geographic Limitations
Form CMS-10434 #22 HH4A – 1945A Health Homes Services
Form CMS-10434 #22 HH5A – 1945A Health Homes Providers
Form CMS-10434 #22 HH6A – 1945A Health Homes Delivery Systems
Form CMS-10434 #22 HH7A – 1945A Health Homes Payment Methodologies
Form CMS-10434 #22 HH8A – 1945A Health Homes Monitoring, Quality Measurement, and Evaluation
Form CMS-10434 #22 HH9A – 1945A Health Homes Program Termination
Form CMS-10434 #22 I2A – 1945A Medicaid State Plan
Form CMS-10434 #22 I3A – 1945A Public Comment
Form CMS-10434 #22 I3aA-1945A Public Notice-Process
Form CMS-10434 #22 I4A – 1945A Tribal Input
Form CMS-10434 #22 I5A – 1945A Other Comment
Other-1945 Implementation Guide
Other-1945A Implementation Guide
GenIC #77 (Revision): Medicaid Extended Postpartum Coverage and Continuous Eligibility for Children New 75 5 0 Form CMS-10434 #77 Home Page and Initial Application Forms
Form CMS-10434 #77 Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage
Form CMS-10434 #77 Continuous Eligibility for Children (Revised SPA Template)
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 789 20771 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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