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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #22 - Health Home State Plan Amendment (SPA)
Agency IC Tracking Number:
CMCS
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
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
Health Homes Intro Screenshots
QSSI-MACPro-PRA-HH1.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Population and Enrollment Screenshots
QSSI-MACPro-PRA-HH2.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Geographic Limitations Screenshots
QSSI-MACPro-PRA-HH3.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Services Screenshots
QSSI-MACPro-PRA-HH4.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Providers Screenshots
QSSI-MACPro-PRA-HH5.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Service Delivery Systems – Screenshots
QSSI-MACPro-PRAHH6.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Payment Methodologies – Screenshots
QSSI-MACPro-PRA-HH7.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots
QSSI-MACPro-PRA-HH8.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Health Homes Program Termination – Screenshots
QSSI-MACPro-PRA-HH9.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #22
Submission Summary – Screenshots
QSSI-MACPro-PRA-I1.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Medicaid State Plan – Screenshots
QSSI-MACPro-PRA-I2.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Public Comment – Screenshots
QSSI-MACPro-PRA-I3.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Tribal Input – Screenshots
QSSI-MACPro-PRA-I4.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #22
Other Comment – Screenshots
QSSI-MACPro-PRA-I5.pdf
Yes
Yes
Fillable Fileable
Other-SMDL Letter
22 - Health Home SPA SMD10024.pdf
No
Printable Only
Other-CMCS Informational Bulletin
22 Health Home SPA CIB-12-22-10.pdf
Yes
Yes
Fillable Fileable
Instruction
Implementation Guide IG_Health_Homes_Consolidated_20160129.pdf
Yes
Yes
Fillable Fileable
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:
30
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
30
0
30
0
0
0
Annual IC Time Burden (Hours)
2,400
0
2,400
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Generic Supporting Statement
GenIC 22 - Supporting Statement Health Home SPA (version8).docx
03/08/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.