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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #22 (Revision): Health Home State Plan Amendment (SPA)
Agency IC Tracking Number:
CMCS
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10434 #22
1945 SPA Templates
1945 Health Home SPA Templates (2023 version 1).pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH8 – 1945 Health Homes Monitoring, Quality Measurement, and Evaluation
HH8 clean.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH1A – 1945A Health Homes Introduction
HH1A-1945AHHIntro_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH2A – 1945A Population and Enrollment
HH2A-1945AHHPopEnroll_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH3A – 1945A Geographic Limitations
HH3A -1945AGeoLimits_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH4A – 1945A Health Homes Services
HH4A - 1945AHHServices_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH5A – 1945A Health Homes Providers
HH5A - 1945AHHProviders_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH6A – 1945A Health Homes Delivery Systems
HH6A - 1945AHHServDel_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH7A – 1945A Health Homes Payment Methodologies
HH7A -1945AHHPmtMethl_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH8A – 1945A Health Homes Monitoring, Quality Measurement, and Evaluation
HH8A clean.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
HH9A – 1945A Health Homes Program Termination
HH9A - 1945AHHTerm_Final_v1.0_20220624.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
I2A – 1945A Medicaid State Plan
I2A- 1945A Submission Form.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
I3A – 1945A Public Comment
I3A-1945A Public Comment.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
I3aA-1945A Public Notice-Process
I3aA- 1945A Public Notice-Process.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
I4A – 1945A Tribal Input
I4A-1945A Tribal Input.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
I5A – 1945A Other Comment
I5A-1945A Other Comment.pdf
Yes
Yes
Fillable Fileable
Other-1945 Implementation Guide
1945 Health Home Implementation Guide.pdf clean.pdf
No
Printable Only
Other-1945A Implementation Guide
Consolidated 1945A Implementation Guides (3).pdf track clean.pdf
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
54
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
18
0
18
0
0
0
Annual IC Time Burden (Hours)
54
0
54
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
State Medicaid Director Letter (SMDL) #10-024
SMDL 10-024 (11-16-2010).pdf
09/30/2023
State Medicaid Director Letter (SMDL) #22-004
SMDL 22-004 (08-01-2022).pdf
09/30/2023
CMCS Informational Bulletin (CIB) 12-22-2010
CIB 12-22-2010.pdf
09/30/2023
CMCS Informational Bulletin (CIB) 10-20-2021
CIB 10-20-2021.pdf
09/30/2023
Track Change: 1945 Implementation Guide
1945 Health Home Implementation Guide.pdf track changes.pdf
09/30/2023
Track Change: 1945A Implementation Guide
Consolidated 1945A Implementation Guides (3).pdf track clean.pdf
09/30/2023
Track Change: HH8 – Health Homes Monitoring, Quality Measurement, and Evaluation
HH8 track changes.xlsx
09/30/2023
Track Change: HH8A – 1945A Health Homes Monitoring, Quality Measurement, and Evaluation
HH8A track changes.xlsx
09/30/2023
Generic Supporting Statement
GenIC #22 - GenericSupportingStatement (CMS-2440-F version 6)508.docx
09/30/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.