Information Collection

GenIC #22 - Health Home State Plan Amendment (SPA)

IC 235263 under ICR 201708-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 #22 GenIC #22 - Health Home State Plan Amendment (SPA)	Form
22 - Health Home SPA SMD10024.pdf	Other-SMDL Letter
22 Health Home SPA CIB-12-22-10.pdf	Other-CMCS Informational Bulletin
Implementation Guide IG_Health_Homes_Consolidated_20160129.pdf	Instruction
CMS-10434 #22 Health Homes Intro Screenshots QSSI-MACPro-PRA-HH1.pdf	Form
CMS-10434 #22 Population and Enrollment Screenshots QSSI-MACPro-PRA-HH2.pdf	Form
CMS-10434 #22 Geographic Limitations Screenshots QSSI-MACPro-PRA-HH3.pdf	Form
CMS-10434 #22 Health Homes Services Screenshots QSSI-MACPro-PRA-HH4.pdf	Form
CMS-10434 #22 Health Homes Providers Screenshots QSSI-MACPro-PRA-HH5.pdf	Form
CMS-10434 #22 Health Homes Service Delivery Systems – Screenshots QSSI-MACPro-PRAHH6.pdf	Form
CMS-10434 #22 Health Homes Payment Methodologies – Screenshots QSSI-MACPro-PRA-HH7.pdf	Form
CMS-10434 #22 Health Homes Monitoring, Quality Measurement and Evaluat QSSI-MACPro-PRA-HH8.pdf	Form
CMS-10434 #22 Health Homes Program Termination – Screenshots QSSI-MACPro-PRA-HH9.pdf	Form
CMS-10398 #22 Submission Summary – Screenshots QSSI-MACPro-PRA-I1.pdf	Form
CMS-10434 #22 Medicaid State Plan – Screenshots QSSI-MACPro-PRA-I2.pdf	Form
CMS-10434 #22 Public Comment – Screenshots QSSI-MACPro-PRA-I3.pdf	Form
CMS-10434 #22 Tribal Input – Screenshots QSSI-MACPro-PRA-I4.pdf	Form
CMS-10434 #22 Other Comment – Screenshots QSSI-MACPro-PRA-I5.pdf	Form
GenIC 22 - Supporting Statement Health Home SPA (version8).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #22 - 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 #22	Health Homes Intro Screenshots	QSSI-MACPro-PRA-HH1.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Population and Enrollment Screenshots	QSSI-MACPro-PRA-HH2.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Geographic Limitations Screenshots	QSSI-MACPro-PRA-HH3.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Services Screenshots	QSSI-MACPro-PRA-HH4.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Providers Screenshots	QSSI-MACPro-PRA-HH5.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Service Delivery Systems â Screenshots	QSSI-MACPro-PRAHH6.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Payment Methodologies â Screenshots	QSSI-MACPro-PRA-HH7.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Monitoring, Quality Measurement and Evaluation â Screenshots	QSSI-MACPro-PRA-HH8.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Health Homes Program Termination â Screenshots	QSSI-MACPro-PRA-HH9.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #22	Submission Summary â Screenshots	QSSI-MACPro-PRA-I1.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Medicaid State Plan â Screenshots	QSSI-MACPro-PRA-I2.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Public Comment â Screenshots	QSSI-MACPro-PRA-I3.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Tribal Input â Screenshots	QSSI-MACPro-PRA-I4.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #22	Other Comment â Screenshots	QSSI-MACPro-PRA-I5.pdf	Yes	Yes	Fillable Fileable
Other-SMDL Letter			22 - Health Home SPA SMD10024.pdf	No		Printable Only
Other-CMCS Informational Bulletin			22 Health Home SPA CIB-12-22-10.pdf	Yes	Yes	Fillable Fileable
Instruction			Implementation Guide IG_Health_Homes_Consolidated_20160129.pdf	Yes	Yes	Fillable Fileable

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: 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
	Approved	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
Generic Supporting Statement	GenIC 22 - Supporting Statement Health Home SPA (version8).docx	03/08/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.