GenIC #47 (Extension w/o change): Health Home Core Sets

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

⚠️ Notice: This information collection may be referencing outdated material.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
47 - Health Homes Quality Measures Consolidated IG.pdf Instruction
47 - Supporting Statement Health Home Core Sets.docx #47 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #47 (Extension w/o change): Health Home Core Sets	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			47 - Health Homes Quality Measures Consolidated IG.pdf		Yes	Yes	Fillable Fileable

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)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#47 - Supporting Statement	47 - Supporting Statement Health Home Core Sets.docx	01/12/2018

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