Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I

Forms and Documents

Document Name	Status
Form CMS-10204 Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I Form and Instruction	New
Form CMS-10204 Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I Form and Instruction	New
CMS-10204.Supporting Statement Part B.doc Supporting Statement B	0000-00-00
CMS-10204.CMS response to AARP comments.doc Supplementary Document	0000-00-00
CMS-10204.AARP Public Comment.pdf Supplementary Document	0000-00-00
CMS-10204.Draft Supporting Statement.8-1-06.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
179027	Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I Form and Instruction	New
179026	Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I Form and Instruction	New

ICR Details

OMB Control No: 0938-1025	ICR Reference No: 200703-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I
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 without change	Conclusion Date: 09/20/2007
	Date Received in OIRA: 03/14/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	36 Months From Approved
Responses	310	0	0
Time Burden (Hours)	298	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This request seeks Office of Management and Budget (OMB) approval of (1) collection of enrollment data by demonstration sites and (2) face-to-face interviews with Medicare beneficiaries (not to exceed 45 minutes in length). These data collection and interviews are to be completed during Phase I of the Evaluation of the Medical Adult Day-Care Services Demonstration (Contract Number 500-00-0038/5). Section 703 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (Pub. L. 108-173) authorizes a three-year demonstration to assess the clinical and cost-effectiveness of providing medical adult day-care services as a substitute for a portion of home health services that would otherwise be provided in the beneficiary's home. Under this authority, the Centers for Medicare & Medicaid Services (CMS), through its Office of Research, Development and Information (ORDI), is conducting the Medical Adult Day-Care Services Demonstration. Five Medicare certified home health agencies were selected by CMS through a competitive process to participate in the demonstration. These five demonstration sites are Aurora Visiting Nurse Association (Milwaukee, Wisconsin), Doctors Care Home Health (McAllen, Texas), Landmark Home Health Care Services (Allison Park, Pennsylvania), Metropolitan Jewish Health System (Brooklyn, New York) and Neighborly Care Network (St. Petersburg, Florida).

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Authorizing Statute(s): PL: Pub.L. 108 - 173 703(h) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
  

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 55479	09/22/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 5054	02/02/2007
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I	CMS-10204	CMS-10204 - Instruments (Appendices B,C,D,E)
Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I	CMS-10204	CMS-10204 - Instruments (Appendices B,C,D,E)

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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	310	0	0	310	0	0
Annual Time Burden (Hours)	298	0	0	298	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: The legal justification for conducting the Demonstration is provided by Section 703 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Public Law 108-173), which authorizes a three-year demonstration to permit a home health agency, directly or under arrangements with a medical adult day-care facility, to provide medical adult day-care services as a substitute for a portion of home health services that would otherwise be provided in the beneficiary's home.

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Annual Cost to Federal Government: $167

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: 03/14/2007

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