Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
8243	Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration	Form	Migrated

ICR Details

OMB Control No: 0938-0662	ICR Reference No: 199605-0938-002
Status: Historical Active	Previous ICR Reference No: 199503-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/1996
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/03/1996
Terms of Clearance: This extension of the PACE Demonstration is approved for use through 9/97 under the condition that no later than November 1996 HCFA: 1) submits to OMB the "Interim Analysis of the PACE Enroll- ment Decision" and "Preliminary Impact Report"; and 2) meets with OMB to discuss report findings, the status of projected baseline and follow-up interviews, and future plans for the Demonstration beyond September 1997 (in particular for the last sample of baseline interviews to be completed in March 1997.) OMB requests this meeting because it continues to be concerned that after five years evaluating the PACE Demonstration, HCFA has not produced an analysis on the impact of the demonstration. Finally, HCFA must immediately incorporate into the forms/instructions the disclosure statements required by the Paperwork Reduction Act of 1995 and its implementing regulations. HCFA must provide OMB the revised forms/instructions for the public record.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/1997	09/30/1997	07/31/1996
Responses	3,739	0	4,675
Time Burden (Hours)	3,745	0	5,436
Cost Burden (Dollars)	0	0	0

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Abstract: This survey will collect data on functional status, service utilization, and out-of-pocket costs and satisfaction for a sample of applicants to the PACE program. This information will be used to analyze the decision to participate in PACE and the impact of the program.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration	HCFA-R-165

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,739	4,675	0	-936	0	0
Annual Time Burden (Hours)	3,745	5,436	0	-1,691	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/03/1996

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