Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10194 Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Form and Instruction	New	Available
Form CMS-10194 Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Form and Instruction	New	Repair queued
CMS-10194 Survey_Cov_Letter.doc	Supplementary Document	Uploaded 2007-01-08	Available
CMS-10194.Supporting Statement Part B.doc	Supporting Statement B	Uploaded 2006-09-22	Available
SNP-OMB Appx E - NHPG Comments.pdf	Supplementary Document	Uploaded 2006-09-22	Available
SNP-OMB text 8_23.Supporting Statement A & B.pdf	Supporting Statement A	Uploaded 2006-09-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45543	Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Form and Instruction	New
45542	Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Form and Instruction	New

ICR Details

OMB Control No: 0938-1010	ICR Reference No: 200610-0938-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/09/2007
	Date Received in OIRA: 10/04/2006
Terms of Clearance: Approved consistent with memo dated 1/8/2007.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	36 Months From Approved
Responses	350	0	0
Time Burden (Hours)	375	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is conducting an Evaluation of Medicare Advantage Special Needs Plans (SNPs), which includes developing profiles of all SNPs that describe the structure and operation of these plans. A one-time short mail questionnaire will gather information about SNPs that is not available from other sources, such as reason for becoming a SNP, and information on care coordination. One-time 90-minute focus groups conducted during site visits to 15 SNPs will provide information on beneficiary experiences in SNPs, including decision to enroll and use of special services.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 231 Name of Law: SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS.
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 30409	05/26/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 55478	09/22/2006
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	CMS-10194, CMS-10194, CMS-10194	SNP-OMB Appx C FocusGroupBeneForm ,   FocuGroupModeratorGuide ,   SNP-OMB Appx C Focus Group Bene Form
Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	CMS-10194, CMS-10194, CMS-10194	SNP-OMB Appx C FocusGroupBeneForm ,   FocuGroupModeratorGuide ,   SNP-OMB Appx C Focus Group Bene Form

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ICR Summary of Burden

table that charts list 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	350	0	0	350	0	0
Annual Time Burden (Hours)	375	0	0	375	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $171,330

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: 09/25/2006

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