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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.