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

Forms and Documents

Document Name	Status
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A) Form and Instruction	Modified
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A) Form and Instruction	New
Supporting Statement (C).doc Supporting Statement B	0000-00-00
attachment 01.pdf Supplementary Document	0000-00-00
attachment 02.pdf Supplementary Document	0000-00-00
attachment 09.pdf Supplementary Document	0000-00-00
Attachment 10.zip Supplementary Document	0000-00-00
attachment 11.xls Supplementary Document	0000-00-00
Attachment 12(a).zip Supplementary Document	0000-00-00
attachment 12(b).pdf Supplementary Document	0000-00-00
attachment 13.pdf Supplementary Document	0000-00-00
attachment 14.pdf Supplementary Document	0000-00-00
attachments 05_07_08 cover.pdf Supplementary Document	0000-00-00
Supporting Statement (A-B).doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
8171	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A) Form and Instruction	Modified
178995	Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A) Form and Instruction	New

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
	Date Received in OIRA: 03/12/2007
Terms of Clearance:

	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

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

	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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