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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:
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
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
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:
20
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
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
Documents for IC
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.