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

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

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GenIC #22 - Health Home State Plan Amendment (SPA) CMCS
 
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-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 – Screenshots QSSI-MACPro-PRAHH6.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Health Homes Payment Methodologies – Screenshots QSSI-MACPro-PRA-HH7.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots QSSI-MACPro-PRA-HH8.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Health Homes Program Termination – Screenshots QSSI-MACPro-PRA-HH9.pdf Yes Yes Fillable Fileable
Form CMS-10398 #22 Submission Summary – Screenshots QSSI-MACPro-PRA-I1.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Medicaid State Plan – Screenshots QSSI-MACPro-PRA-I2.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Public Comment – Screenshots QSSI-MACPro-PRA-I3.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Tribal Input – Screenshots QSSI-MACPro-PRA-I4.pdf Yes Yes Fillable Fileable
Form CMS-10434 #22 Other Comment – 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

Health Health Care Services

 

30 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 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
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.