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GenIC 22 (Revision): Health Home State Plan Amendment (SPA) CMCS
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form A1 - A5, HH1 - HH9, I1 - I5, and S (misc.) 1945 Health Home SPA Templates #22 - 1945 Health Home SPA Templates.pdf Yes Yes Fillable Fileable
Form HH1A 1945A Health Homes Introduction HH1A-1945AHHIntro_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH2A 1945A Population and Enrollment HH2A-1945AHHPopEnroll_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH3A 1945A Geographic Limitations HH3A -1945AGeoLimits_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH4A 1945A Health Homes Services HH4A - 1945AHHServices_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH5A 1945A Health Homes Providers HH5A - 1945AHHProviders_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH6A 1945A Health Homes Delivery Systems HH6A - 1945AHHServDel_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH7A 1945A Health Homes Payment Methodologies HH7A -1945AHHPmtMethl_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH8A 1945A Health Homes Monitoring, Quality Measurement, and Evaluation HH8A - 1945AHHMonitoring_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form HH9A 1945A Health Homes Program Termination HH9A - 1945AHHTerm_Final_v1.0_20220624.pdf Yes Yes Fillable Fileable
Form I2A 1945A Submission Summary I2A- 1945A Submission Form.pdf Yes Yes Fillable Fileable
Form I3A 1945A Public Comment I3A-1945A Public Comment.pdf Yes Yes Fillable Fileable
Form I3aA 1945A Public Notice-Process I3aA- 1945A Public Notice-Process.pdf Yes Yes Fillable Fileable
Form I4A 1945A Tribal Input I4A-1945A Tribal Input.pdf Yes Yes Fillable Fileable
Form I5A 1945A Other Comment I5A-1945A Other Comment.pdf Yes Yes Fillable Fileable
Instruction 1945 Health Home Consolidated Implementation Guide.pdf Yes No Printable Only
Instruction 1945A Health Home Consolidated Implementation Guide.pdf.docx Yes No Printable Only
Instruction CMCS Informational Bulletin 12-22-2010.pdf Yes No Printable Only
Instruction CMCS Informational Bulletin 10-20-2021.pdf Yes No Printable Only

Health Health Care Services

 

20 0
   
State, Local, and Tribal Governments
 
   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 20 0 20 0 0 0
Annual IC Time Burden (Hours) 1,600 0 1,600 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SMDL #10-024 SMDL 10-024.pdf 08/02/2022
SMDL #22-004 SMDL 22-004.pdf 08/02/2022
GenIC #22 - Generic Supporting Statement GenIC 22 - Generic Supporting Statement (2022 version 8).docx 08/02/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.