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GenIC #22 (Revision): Health Home State Plan Amendment (SPA) CMCS
 
New
 
Mandatory
 

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

Health Health Care Services

 

54 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 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

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.