Information Collection

GenIC 22 (Revision): Health Home State Plan Amendment (SPA)

IC 254721 under ICR 201908-0938-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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 A1 - A5, HH1 - HH9 1945 Health Home SPA Templates GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH1A 1945A Health Homes Introduction GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH2A 1945A Population and Enrollment GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH3A 1945A Geographic Limitations GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH4A 1945A Health Homes Services GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH5A 1945A Health Homes Providers GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH6A 1945A Health Homes Delivery Systems GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH7A 1945A Health Homes Payment Methodologies GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH8A 1945A Health Homes Monitoring, Quality Measurement, and Evaluation GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form HH9A 1945A Health Homes Program Termination GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form I2A 1945A Submission Summary GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form I3A 1945A Public Comment GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form I3aA 1945A Public Notice-Process GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form I4A 1945A Tribal Input GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
Form I5A 1945A Other Comment GenIC 22 (Revision): Health Home State Plan Amendment (SPA)	Form
1945 Health Home Consolidated Implementation Guide.pdf	Instruction
1945A Health Home Consolidated Implementation Guide.pdf.docx	Instruction
CMCS Informational Bulletin 12-22-2010.pdf	Instruction
CMCS Informational Bulletin 10-20-2021.pdf	Instruction
A1 - A5, HH1 - HH9 1945 Health Home SPA Templates #22 - 1945 Health Home SPA Templates.pdf	Form
HH1A 1945A Health Homes Introduction HH1A-1945AHHIntro_Final_v1.0_20220624.pdf	Form
HH2A 1945A Population and Enrollment HH2A-1945AHHPopEnroll_Final_v1.0_20220624.pdf	Form
HH3A 1945A Geographic Limitations HH3A -1945AGeoLimits_Final_v1.0_20220624.pdf	Form
HH4A 1945A Health Homes Services HH4A - 1945AHHServices_Final_v1.0_20220624.pdf	Form
HH5A 1945A Health Homes Providers HH5A - 1945AHHProviders_Final_v1.0_20220624.pdf	Form
HH6A 1945A Health Homes Delivery Systems HH6A - 1945AHHServDel_Final_v1.0_20220624.pdf	Form
HH7A 1945A Health Homes Payment Methodologies HH7A -1945AHHPmtMethl_Final_v1.0_20220624.pdf	Form
HH8A 1945A Health Homes Monitoring, Quality Measurement, and HH8A - 1945AHHMonitoring_Final_v1.0_20220624.pdf	Form
HH9A 1945A Health Homes Program Termination HH9A - 1945AHHTerm_Final_v1.0_20220624.pdf	Form
I2A 1945A Submission Summary I2A- 1945A Submission Form.pdf	Form
I3A 1945A Public Comment I3A-1945A Public Comment.pdf	Form
I3aA 1945A Public Notice-Process I3aA- 1945A Public Notice-Process.pdf	Form
I4A 1945A Tribal Input I4A-1945A Tribal Input.pdf	Form
I5A 1945A Other Comment I5A-1945A Other Comment.pdf	Form
SMDL 10-024.pdf SMDL #10-024	IC Document
SMDL 22-004.pdf SMDL #22-004	IC Document
GenIC 22 - Generic Supporting Statement (2022 version 8).docx GenIC #22 - Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC 22 (Revision): 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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	A1 - A5, HH1 - HH9, I1 - I5, and S (misc.)	Yes	Yes	Fillable Fileable
Form	HH1A	Yes	Yes	Fillable Fileable
Form	HH2A	Yes	Yes	Fillable Fileable
Form	HH3A	Yes	Yes	Fillable Fileable
Form	HH4A	Yes	Yes	Fillable Fileable
Form	HH5A	Yes	Yes	Fillable Fileable
Form	HH6A	Yes	Yes	Fillable Fileable
Form	HH7A	Yes	Yes	Fillable Fileable
Form	HH8A	Yes	Yes	Fillable Fileable
Form	HH9A	Yes	Yes	Fillable Fileable
Form	I2A	Yes	Yes	Fillable Fileable
Form	I3A	Yes	Yes	Fillable Fileable
Form	I3aA	Yes	Yes	Fillable Fileable
Form	I4A	Yes	Yes	Fillable Fileable
Form	I5A	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only

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: 20

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	20	20
Annual IC Time Burden (Hours)	1,600	1,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SMDL #10-024		08/02/2022
SMDL #22-004		08/02/2022
GenIC #22 - Generic Supporting Statement		08/02/2022

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

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