#22: Health Home State Plan Amendment (SPA)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

OMB: 0938-1148

IC ID: 214328

Information Collection (IC) Details

View Information Collection (IC)

#22: Health Home State Plan Amendment (SPA)
 
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 CMS-10398 (#22) Health Homes Administrative Report MMDLHealthHomesAdminReportBlankTestState.pdf Yes Yes Fillable Printable
Form CMS-10398 (#22) Health Home State Plan Amendment MMDLHealthHomesBlankTestState.pdf Yes Yes Fillable Printable

Health Health Care Services

 

30 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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

Title Document Date Uploaded
#22 Supporting Statement: Health Home State Plan Amendment (SPA) #22 Health Home SPA Supporting Statement [Dec 2014].docx 12/22/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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