Information Collection

#22: Health Home State Plan Amendment (SPA)

IC 214328 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#22) #22: Health Home State Plan Amendment (SPA) Form
CMS-10398 (#22) Health Homes Administrative Report MMDLHealthHomesAdminReportBlankTestState.pdf Form
CMS-10398 (#22) Health Home State Plan Amendment MMDLHealthHomesBlankTestState.pdf Form
#22 Health Home SPA Supporting Statement [Dec 2014].docx #22 Supporting Statement: Health Home State Plan Amendment (SPA) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#22: Health Home State Plan Amendment (SPA)	Agency IC Tracking Number:

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-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

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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	2,400	2,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.