Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-P-0015A MCBS Household Round 46 Show Cards	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Household Round 46 Questionnaire Spanish	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Household Round 46 Questionnaire English	Form and Instruction	Modified	Available
Form CMS-P-0015A Facility Screening Interview Script	Form and Instruction	Modified	Repair queued
Form CMS-P-0015A MCBS Facility Round 46 Use of Services Module	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Facility Round 46 Prescription Medicines	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Facility Round 46 Resident History	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Facility Round 46 Health Status Base Line	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Facility Round 46 Health Ins Questionnaire	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Facility Round 46 Expenditure Questionnaire	Form and Instruction	Modified	Available
Form CMS-P-0015A Background Questionnaire	Form and Instruction	Modified	Available
Form CMS-P-0015A MCBS Household Round 46 Show Cards	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Household Round 46 Questionnaire Spanish	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Household Round 46 Questionnaire English	Form and Instruction	New	Repair queued
Form CMS-P-0015A Facility Screening Interview Script	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Use of Services Module	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Prescription Medicines	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Resident History	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Health Status Base Line	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Health Ins Questionnaire	Form and Instruction	New	Available
Form CMS-P-0015A MCBS Facility Round 46 Expenditure Questionnaire	Form and Instruction	New	Available
Form CMS-P-0015A Background Questionnaire	Form and Instruction	New	Available
Supporting Statement (C).doc	Supporting Statement B	Uploaded 0000-00-00	Available
attachment 01.pdf	Supplementary Document	Uploaded 0000-00-00	Available
attachment 02.pdf	Supplementary Document	Uploaded 0000-00-00	Available
attachment 09.pdf	Supplementary Document	Uploaded 0000-00-00	Available
Attachment 10.zip	Supplementary Document	Uploaded 0000-00-00	Available
attachment 11.xls	Supplementary Document	Uploaded 0000-00-00	Available
Attachment 12(a).zip	Supplementary Document	Uploaded 0000-00-00	Available
attachment 12(b).pdf	Supplementary Document	Uploaded 0000-00-00	Available
attachment 13.pdf	Supplementary Document	Uploaded 0000-00-00	Available
attachment 14.pdf	Supplementary Document	Uploaded 0000-00-00	Available
attachments 05_07_08 cover.pdf	Supplementary Document	Uploaded 0000-00-00	Available
Supporting Statement (A-B).doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Household Round 46 Show Cards
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Household Round 46 Questionnaire Spanish
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Household Round 46 Questionnaire English
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	Facility Screening Interview Script
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Use of Services Module
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Prescription Medicines
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Resident History
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Health Status Base Line
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Health Ins Questionnaire
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	MCBS Facility Round 46 Expenditure Questionnaire
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	Modified	Background Questionnaire
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Household Round 46 Show Cards
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Household Round 46 Questionnaire Spanish
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Household Round 46 Questionnaire English
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	Facility Screening Interview Script
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Use of Services Module
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Prescription Medicines
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Resident History
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Health Status Base Line
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Health Ins Questionnaire
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	MCBS Facility Round 46 Expenditure Questionnaire
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction	New	Background Questionnaire

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 200703-0938-003
Status: Historical Active	Previous ICR Reference No: 200401-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)
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: 08/23/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/12/2007
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	49,500	0	49,500
Time Burden (Hours)	50,325	0	50,325
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries. The core of the MCBS is a series of interviews with a stratified random sample of the Medicare population, including aged and disabled enrollees, residing in the community or in institutions. Questions are asked about enrollees' patterns of health care use, charges, insurance coverage, and payments over time. Respondents are asked about their sources of health care coverage and payment, their demographic characteristics, their health and work history, and their family living circumstances. In addition to collecting information through the core questionnaire, the MCBS collects information on special topics through supplements. For example, questions are asked about enrollees' income and assets, access to health care, health and functional status and satisfaction with care. Special supplements also focus on emerging trends in health care.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 67873	11/24/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 5055	02/02/2007
Did the Agency receive public comments on this ICR? No

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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
Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A	Background Questionnaire ,   MCBS Facility Round 46 Expenditure Questionnaire ,   MCBS Facility Round 46 Health Ins Questionnaire ,   MCBS Facility Round 46 Health Status Base Line ,   MCBS Facility Round 46 Resident History ,   MCBS Facility Round 46 Prescription Medicines ,   MCBS Facility Round 46 Use of Services Module ,   Facility Screening Interview Script ,   MCBS Household Round 46 Questionnaire English ,   MCBS Household Round 46 Questionnaire Spanish ,   MCBS Household Round 46 Show Cards
Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A	Background Questionnaire ,   MCBS Facility Round 46 Expenditure Questionnaire ,   MCBS Facility Round 46 Health Ins Questionnaire ,   MCBS Facility Round 46 Health Status Base Line ,   MCBS Facility Round 46 Resident History ,   MCBS Facility Round 46 Prescription Medicines ,   MCBS Facility Round 46 Use of Services Module ,   Facility Screening Interview Script ,   MCBS Household Round 46 Questionnaire English ,   MCBS Household Round 46 Questionnaire Spanish ,   MCBS Household Round 46 Show Cards

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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	49,500	49,500	0	0	0	0
Annual Time Burden (Hours)	50,325	50,325	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There was no burden change, however; the system requiured a Program Change selection.

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Annual Cost to Federal Government: $14,935,000

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: 03/12/2007

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