Medicare Lifestyle Modification Program Demonstration

ICR 200205-0938-012

OMB: 0938-0871

Federal Form Document

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
8689 Migrated
ICR Details
0938-0871 200205-0938-012
Historical Active
HHS/CMS
Medicare Lifestyle Modification Program Demonstration
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/25/2002
Retrieve Notice of Action (NOA) 05/20/2002
Approved for use through 7/2005 under the condition that prior to fielding this instrument, CMS submits to OMB a plan for: 1) tracking response rates for the drug utilization and cost questions, 2) comparing these data to similar information from surveys such as the MEPS and MCBS; 3) sharing this information with OMB as soon as it is available during the survey effort. In addition,OMB appreciates the thorough justification for the use of payment incentives in this effort, but emphasizes that acceptance of incentives in this case should not be perceived as a precedent for future PRA submissions. OMB will continue to evaluate the use of incentives on a case-by-case basis.
  Inventory as of this Action Requested Previously Approved
07/31/2005 07/31/2005
1,680 0 0
1,106 0 0
0 0 0

This demonstration will focus on two Medicare sponsored, lifestyle modification programs designed to reverse, reduce or ameliorate the progression of coronary artery disease (CAD) at risk for significant morbidity and mortality. This demonstration will test the cost-effectiveness and feasibility of providing payment for cardiovascular lifestyle modification program services to Medicare beneficiaries.

None
None


No

1
IC Title Form No. Form Name
Medicare Lifestyle Modification Program Demonstration CMS-10044

  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 1,680 0 0 1,680 0 0
Annual Time Burden (Hours) 1,106 0 0 1,106 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/20/2002


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