Inventory of Active GenICs

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

09/12/2022

Department of Health and Human Services
Centers for Medicare & Medicaid Services
FOR CERTIFYING OFFICIAL:

Karl Mathias

FOR CLEARANCE OFFICER:

Sherrette Funn

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
08/02/2022
ACTION REQUESTED: Generic IC
GenIC 22 (Revision): Health Home State Plan Amendment (SPA)
IC TITLE:
ICR REFERENCE NUMBER:

201908-0938-015

AGENCY ICR TRACKING NUMBER:
TITLE:

CMCS

Medicaid and CHIP Program (MACPro) (CMS-10434)

LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

0938-1188

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 07/31/2023

BURDEN:

DISCONTINUE DATE:

RESPONSES

HOURS

COSTS

Previous

280

96,844

0

New

280

96,844

0

Change due to New Statute

0

0

0

Change due to Agency Discretion

0

0

0

Change due to Agency Adjustment

0

0

0

Change due to PRA Violation

0

0

0

Difference

TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Deputy Administrator,
Office Of Information And Regulatory Affairs

IC Title

Form No.

List of ICs
Form Name

GenIC #1 (Extension) - CMS-10434 #1, CMS- Initial Application SPA
Initial Application
10434 #1, CMS-10434 Admin, Initial Application,
#1
Initial Application
Combined
GenIC #2 (Extension) - CMS-10434 #2
CHIP State Plan Eligibility
CHIP State Plan
Eligibility
GenIC #3 (Extension) - CMS-10434 #3
ABP
Alternative Benefit
Plans (ABPs)
GenIC #22 (Extension) - CMS-10434 #22
Health Homes
Health Home State Plan
Amendment (SPA)
GenIC #47 (Extension) - CMS-10434 #47
Health Home Core Set
Health Home Core Sets
GenIC #15 (Extension) - CMS-10434 #15
Medicaid State Plan
Medicaid State Plan
Eligibility
Eligibility
GenIC #26 (Extension) - 385-CQM 2018-ADD- CQM 2018 - Follow-Up
Medicaid Adult and
CH-PRA-D, 245-QSSI- Care for Children
Child Core Set
MACPro-PRAPrescribed AttentionMeasures
AdditionalNotes-D, 390- Deficit/Hyperactivity
CQM 2018-CCW-CH- Disorder (ADHD)
PRA-D, 385-CQM
Medication (ADD-CH)
2018-ADD-CH-PRA-D, Core Measure PRA
429-AQM 2018 ABA-AD Document, AQM, CQM &
PRA-D
MIH - Additional Notes
PRA document,
Contraceptive Care – All
Women Ages 15-20
(CCW-CH), CQM 2018 Follow-Up Care for
Children Prescribed
AttentionDeficit/Hyperactivity
Disorder (ADHD)
Medication (ADD-CH)
Core Measure PRA
Document, AQM 2018 –
Adult Body Mass Index
Assessment (ABA) Core
Measure PRA document
GenIC # 45 (Extension) CMS-10434 #45
Maternal and Infant Health
- Maternal and Infant
Health Quality
GenIC #77 (New):
CMS-10434 #77, CMS- Continuous Eligibility for
Medicaid Extended
10434 #77, CMS-10434 Children (reviewable unit
Postpartum Coverage #77
screenshots), Home Page
and Continuous
and Initial Application
Eligibility for Children
Forms, Continuous
Eligibility for Pregnant
Women and Extended
Postpartum Coverage
(reviewable unit
screenshots)

CFR Citation

Hrs/$/Resp
476 / 0 / 56

1,568 / 0 / 56
728 / 0 / 56
2,400 / 0 / 30
1,200 / 0 / 30
1,120 / 0 / 56
8,960 / 0 / 224

112 / 0 / 112
2,548 / 0 / 56

IC Title

Form No.

GenIC 22 (Revision):
I5A, I2A, I3A, A1 - A5,
Health Home State Plan HH1 - HH9, I1 - I5, and
Amendment (SPA)
S (misc.), HH6A, HH5A,
HH4A, HH3A, HH2A,
HH1A, HH8A, I4A,
HH7A, HH9A, I3aA

List of ICs
Form Name

CFR Citation

1945A Other Comment,
1945A Submission
Summary, 1945A Public
Comment, 1945 Health
Home SPA Templates,
1945A Health Homes
Delivery Systems, 1945A
Health Homes Providers,
1945A Health Homes
Services, 1945A
Geographic Limitations,
1945A Population and
Enrollment, 1945A Health
Homes Introduction,
1945A Health Homes
Monitoring, Quality
Measurement, and
Evaluation, 1945A Tribal
Input, 1945A Health
Homes Payment
Methodologies, 1945A
Health Homes Program
Termination, 1945A Public
Notice-Process
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
1,600 / 0 / 20

20,712