Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10203 EG Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)	Form and Instruction	Modified	Available
Jan 24 Supporting Statement B_final.doc	Supporting Statement B	Uploaded 2007-01-24	Available
Attachment 8(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 7c(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 7b(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 7a(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 5b(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 5a(2).pdf	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 2(2).doc	Supplementary Document	Uploaded 2007-01-24	Available
Attachments TOC(2).doc	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 9(2).doc	Supplementary Document	Uploaded 2007-01-24	Available
Attachment 1.doc	Supplementary Document	Uploaded 2007-01-24	Available
Jan 24 Supporting Statement A_final.doc	Supporting Statement A	Uploaded 2007-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8327	Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0701	ICR Reference No: 200701-0938-016
Status: Historical Active	Previous ICR Reference No: 200309-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2007
	Date Received in OIRA: 01/25/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2007
Responses	320,040	0	1,569
Time Burden (Hours)	105,613	0	429,598
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services (formerly HCFA) collects quality performance measures in order to hold the Medicare managed care industry accountable for the care being delivered, to enable quality improvement, and to provide quality information to Medicare beneficiaries in order to promote an informed choice. It is critical to CMS's mission that we collect and disseminate information that can be used to help beneficiaries choose among health plans, contribute to improved quality of care through identification of improvement opportunities, and assist CMS in carrying out its oversight and purchasing responsibilities.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   US Code: 42 USC 442, Subpart D Name of Law: null
  

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 46483	08/14/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 63018	10/27/2006
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)	CMS-10203 EG, CMS-10203 SP, CMS-10203 CH, CMS-10203 EGM, CMS-10203 SPM, CMS-10203 CHM	HOS Questionnaire English ,   HOS Questionnaire Spanish ,   HOS Questionnaire Chinese ,   HOS Modified Questionnaire English ,   HOS Modified Questionnaire Spanish ,   HOS Modified Questionnaire Chinese

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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	320,040	1,569	0	0	318,471	0
Annual Time Burden (Hours)	105,613	429,598	0	0	-323,985	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $235,090

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: 01/25/2007

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