Evaluation of the Medical Adult Day Care Services Demonstration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10204 Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I	Form and Instruction	Removed	Available
8[1].1.08FinalContractresponsetoOMB.DOC	Supplementary Document	Uploaded 2008-08-06	Available
Supporting Statement B.doc	Supporting Statement B	Uploaded 2008-04-25	Available
8[1].1.08OMBpassbackfinalsupportingstatement.doc	Supporting Statement A	Uploaded 2008-08-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178665	Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I	Form and Instruction	Removed
178664	Evaluation of the Medical Adult Day Care Services Demonstration (CMS-10204)	Other-Form, Instructions and Appendices (CMS-10204)	Modified

ICR Details

OMB Control No: 0938-1017	ICR Reference No: 200805-0938-005
Status: Historical Active	Previous ICR Reference No: 200702-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Evaluation of the Medical Adult Day Care Services Demonstration
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/15/2008
	Date Received in OIRA: 05/06/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved	04/30/2010
Responses	900	0	310
Time Burden (Hours)	150	0	298
Cost Burden (Dollars)	0	0	0

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Abstract: CMS has contracted with Brandeis University under contract number 500-00-0038/5 to perform the evaluation. The evaluation will conduct "an analysis of the patient outcomes and costs of furnishing care to the Medicare beneficiaries participating in the project as compared to such outcomes and costs to beneficiaries receiving only home health services for the same health conditions." Delivering home health services in the adult day-care setting represents an expansion of coverage under the home health benefit under Medicare. The Demonstration requires the assurance of budget neutrality regardless of whether services are delivered in the home or in the adult day-care facility. Based on learning from the beneficiary interviews conducted in Phase I, Brandeis has developed and pre-tested a satisfaction survey to be administered to up to 900 beneficiaries in Phase II. The satisfaction survey has been designed to assess the domains and degrees of satisfaction with home health care among beneficiaries who participated in and refused to participate in the Demonstration. It will also collect information about the types and extent of out-of-pocket costs related to home care and adult day services. These data will be used by the evaluator to assess differences in satisfaction and out-of-pocket costs among the Demonstration sites, between participants and refusers, and according to other beneficiary characteristics assessed in the survey.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 703 Name of Law: Demonstration Project For
  

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:
	73 FR 7560	02/08/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22418	04/25/2008
Did the Agency receive public comments on this ICR? Yes

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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
Evaluation of the Medical Adult Day Care Services Demonstration (CMS-10204)
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

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	900	310	0	590	0	0
Annual Time Burden (Hours)	150	298	0	-148	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: The burden hours have decreased because this is a 10 minute telephone beneficiary satisfaction survey that will be conducted in phase two of this evaluation. The collection of data conducted in Phase One were face to face interviews with beneficiaries which required more time. The initial collection request was approved in OMB number 0938-1017, April 27, 2007

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Annual Cost to Federal Government: $141,385

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: 05/06/2008

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