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Agenda
Reg Review
ICR
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
To view an IC, click on IC Title