Medicare+Choice Disenrollment Form to Original Medicare

Forms and Documents

Document Name	Status

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

IC Document Collections

IC ID	Document Title	Status
8425	Medicare+Choice Disenrollment Form to Original Medicare Form	Migrated

ICR Details

OMB Control No: 0938-0741	ICR Reference No: 199809-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare+Choice Disenrollment Form to Original Medicare
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/02/1998
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/09/1998
	Date Received in OIRA: 09/22/1998
Terms of Clearance: Approved for use through 4/1999 under the condition that in the next submission HCFA provides: 1) an additional update on its progress in linking with or replacing this telephone form for the face-to-face HCFA-566 used by SSA; 2) more detail on its plans to analyze response bias for the new HCFA R-257 and any preliminary findings; 3) an assessment of the feasibility of completing this form by beneficiaries; and 4) a crosswalk between the categories on this form and any current or future planned questions in the Medicare CAHPS.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/1999	04/30/1999
Responses	60,000	0	0
Time Burden (Hours)	3,960	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 4001 of the Balanced Budget Act of 1997 amended the Social Security Act to add section 1851, including 1851(c)(1), which required the establishment of a procedure and form to make and change Medicare+Choice elections, which include disenrollment. In addition, BBA of 1997 also required information be provided to beneficiaries to make informed better choices, specifically quality and performance indicators --disenrollment rates are specifically included as part of this information. This disenrollment form is necessary to process the disenrollment action as a change....

Emergency Justfication:

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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
Medicare+Choice Disenrollment Form to Original Medicare	HCFA-R-257

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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	60,000	0	0	60,000	0	0
Annual Time Burden (Hours)	3,960	0	0	3,960	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

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? No

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: 09/22/1998

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