CMS-10318.Supporting Statement Parts A and B - FINAL_508COMPL

Request for Clearance:
Survey to Inform the Children’s Health Insurance Program (CHIP)
National Outreach & Education Campaign

Submitted by:
Christopher Koepke, Ph.D
Director of the Strategic Research and Campaign
Management Group
Centers for Medicare & Medicaid Services (CMS)
Office of External Affairs

April 15, 2010

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Table of Contents
STATEMENT A: JUSTIFICATION............................................................................................................................... 3
CIRCUMSTANCES THAT MAKE THE COLLECTION OF INFORMATION NECESSARY ............................................................................3
PURPOSE AND USE OF INFORMATION COLLECTION ................................................................................................................5
USE OF IMPROVED INFORMATION TECHNOLOGY AND BURDEN REDUCTION ...............................................................................5
EFFORTS TO IDENTIFY DUPLICATION ...................................................................................................................................6
IMPACT ON SMALL BUSINESS OR OTHER SMALL ENTITIES .......................................................................................................6
CONSEQUENCES OF COLLECTING INFORMATION LESS FREQUENTLY ...........................................................................................6
SPECIAL CIRCUMSTANCES RELATING TO GUIDELINES OF 5 CFR 1320 .......................................................................................6
COMMENTS IN RESPONSE TO THE FEDERAL REGISTER NOTICE AND EFFORTS TO CONSULT OUTSIDE THE AGENCY ..............................7
EXPLANATION OF ANY PAYMENTS OR GIFTS TO RESPONDENTS ................................................................................................7
ASSURANCE OF CONFIDENTIALITY PROVIDED TO RESPONDENTS ...............................................................................................7
JUSTIFICATION FOR SENSITIVE QUESTIONS ...........................................................................................................................8
ESTIMATES OF ANNUALIZED BURDEN HOURS AND COSTS .......................................................................................................8
ESTIMATES OF OTHER TOTAL ANNUAL COST BURDEN TO RESPONDENTS AND RECORD KEEPERS ....................................................8
ESTIMATES OF ANNUALIZED COSTS TO THE FEDERAL GOVERNMENT .........................................................................................8
EXPLANATION FOR PROGRAM CHANGES OR ADJUSTMENTS .....................................................................................................9
PLANS FOR TABULATION AND PUBLICATION AND PROJECT TIMES SCHEDULE ..............................................................................9
REASON DISPLAY OF OMB EXPIRATION DATE IS INAPPROPRIATE .............................................................................................9
EXCEPTIONS TO CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS........................................................................9
STATEMENT B: COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS ........................................ 10
RESPONDENT UNIVERSE AND SAMPLING ...........................................................................................................................10
PROCEDURES FOR DATA COLLECTION ...............................................................................................................................11
MAXIMIZING RESPONSE RATES........................................................................................................................................11
TEST OF PROCEDURES....................................................................................................................................................12
CONTACTS ON STATISTICAL METHODS ..............................................................................................................................12

List of Tables
TABLE 1. NATURAL DISTRIBUTION ESTIMATES BY INSURANCE STATUS ...........................................................................................4
TABLE 2. SURVEY ESTIMATES OF BURDEN HOURS .....................................................................................................................8

Attachments
LEGAL AUTHORITY ……………………………………………………………………………………………………………………………………………………………………..
60-DAY FEDERAL REGISTER NOTICE …………………………………………………………………………………………………………………………………………….
CONFIDENTIALITY AGREEMENT ……………………………………………………………………………………………………………………………………………………
SURVEY INVITATION ……………………………………………………………………………………………………………………………………………………………………
SURVEY QUESTIONNAIRE ……………………………………………………………………………………………………………………………………………………………

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Statement A: Justification
Circumstances That make the Collection of Information Necessary
This Information Collection Request (ICR) is for a new data collection entitled Children’s Health
Insurance Program (CHIP) National Outreach & Education Campaign. The request is for three
years starting from the date of OMB approval.
Background.
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law
111-3) reauthorized the Children's Health Insurance Program (CHIP) through FY 2013. It will
preserve coverage for the millions of children who rely on CHIP today and provide the resources
for States to reach millions of additional uninsured children. This legislation will help ensure the
health and well-being of our nation's children. To support this legislation and to help people who
would benefit from CHIP make more informed decisions, CMS will be conducting outreach. The
outreach will employ numerous communications channels to educate people who would benefit
from CHIP concerning the program benefits, eligibility and enrollment requirements, utilization,
and retention. As part of the outreach, CMS will seek to increase awareness, enrollment and
retention in CHIP for the eligible audiences. The primary target audience for the outreach
includes parents and guardians of potentially eligible children as well as pregnant women.
Secondary audiences are information intermediaries including State, local, and tribal
governments, educators (including non-parental caregivers) health care providers /social
workers, national and local partners. The challenge is reaching the population segments that have
access barriers to information including language, literacy, location, and culture to understand
health insurance. To support the outreach and education, CMS needs to conduct survey research
to be able to effectively reach the target audiences.
Nature of the Data Collection.
As part of the effort to determine how to serve most effectively the primary CHIP audience, we
are requesting approval from OMB for a survey that will accomplish several critical tasks:
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Accurately assess the needs of the primary CHIP audience;
Examine awareness and knowledge of CHIP;
Explore motivations for and barriers to enrolling in CHIP;
Monitor awareness of outreach activities;
Gather information on health behaviors, health care utilization and quality of health care;
and
− Help identify key sources of health information for families eligible for a children’s
health insurance program.

Since significant changes in the national economy occurred more than a year ago, little data has
been collected on these topics related to children’s health insurance. The result of this research
will help guide outreach strategies, messages and materials development throughout the course
of the CHIP National Outreach and Education Campaign.
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We propose to survey 1,850 parents or guardians in low-income households (at or below 250
percent of Federal Poverty Level), of which 600 will be parents or guardians in the Latinoeligible population. The sample will include households with children who are currently
uninsured as well as households with children who are currently insured. We defined our sample
by Federal Poverty Level (FPL) rather than insurance status for several reasons. Children
currently insured in Medicaid or CHIP may become uninsured for a period of time and then need
to re-enroll due to the high level of churn associated with these programs. While they may not
have a child currently enrolled, parents in the re-enrollment process would still offer beneficial
insights. Similarly, insights on enrollment from parents with children currently in CHIP or
Medicaid will also prove helpful. Finally, large proportions of this population have had a
household member lose a job (or are at risk for job loss), putting their child’s private insurance
coverage at risk. By conducting a survey among households that represent only currently
uninsured children we would ignore a large target audience segment.
Our sample of 1,850 will consist of the following subsamples:
− N=600 current/recently uninsured
− N=600 Medicaid/CHIP
− N=600 employer coverage
− N=50 other
The subsample sizes of n=600 across insurance categories will allow for segmentation and
regression analyses within each of these subsamples, and for general consistency on reporting
data. The subsamples will be appropriately weighted to reflect the natural distribution by
insurance status, as shown in Table 1:
Table 1. Natural Distribution Estimates by Insurance Status
Insurance Status of Child

Natural Distribution (rounded)

Currently uninsured
Uninsured at any time in past year
(includes currently uninsured)
Medicaid/CHIP
Employer
Individual insurance
Other public (e.g., military)

n=160 (10%)
n=240 (15%)
n=720 (45%)
n=560 (35%)
n=64 (4%)
n=32 (2%)

The natural distribution is based on 2008 and 2009 Child Protective Services (CPS) and
Congressional Budget Office (CBO) estimates.
Of the 1,850 interviews, n=600 interviews will be conducted among a representative sample of
the Latino-eligible population. About 45 percent of Latino respondents prefer to take surveys in
Spanish, according to preferences they indicated as members of our fielding vendor’s panel. The
fielding vendor is Knowledge Networks (KN), and more details about this firm and its
methodologies are provided in subsequent sections of this information collection request (ICR).
Based on this percentage, n=330 interviews will be conducted in English, and n=270 in Spanish.
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Our research plan will allow us to make estimates on the Latino-eligible population generally as
well as analyze data by language preference.
The campaign is targeted at adults 18 years and older. Participants in the survey will be adults 18
years of age or older.
We are requesting a three-year clearance, so that the feedback received through the survey may
be used continually to update and improve research efforts and outreach. The purpose of this
submission is to request OMB authorization to collect information from CHIP’s audience via
survey methodology.
Legal Basis.
CMS is authorized to collect information under the Children's Health Insurance Program
Reauthorization Act of 2009 (CHIPRA or Public Law 111-3), which reauthorized the Children's
Health Insurance Program (CHIP) through FY 2013. See Attachment 1.
Purpose and Use of Information Collection
The information collection will survey the primary target audience of the outreach – parents and
guardians of potentially eligible children. The survey sample will include hard-to-reach people
within the primary target audience. Specifically, the survey will assess the information needs,
knowledge, understanding and experiences of the primary target audience.
CMS is seeking understanding about what types of information the primary CHIP audience
needs. Included in the surveys are questions regarding how well informed the target audience is
about CHIP. The results of this survey will be compiled and studied so that communication may
be amended to benefit the CHIP audience.
Use of Improved Information Technology and Burden Reduction
We intend to work with the fielding vendor, Knowledge Networks (KN), to employ a webenabled survey methodology as the predominant means of collecting data. Unlike any other webbased survey company, KN’s panel is created from probability sampling, using both random
digit dial (RDD) and addressed-based sampling (ABS). Because KN uses ABS, wireless-only
households have an equal chance of being selected for panel recruitment. Additionally, for
households without Internet access or a computer, KN provides both at no cost to ensure
representativeness.
The web-enabled survey methodology reduces burden in several ways. With telephone
interviews, respondents tend to be interrupted by the phone call and typically make repeated
attempts to end the interview. With the KN online approach, however, respondents can choose to
take the survey at their own convenience and pause and return to the survey if interrupted. In
addition, response data are entered automatically and directly into a database, eliminating the
need for time-consuming coding and data entering.

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The KN web-enabled methodology was chosen because of its success in reaching low-incidence
populations. A primary goal of this project is to meet a targeted number of interviews for the
vulnerable group of parents with children who either do not currently have health insurance or
recently have not had health insurance. Each of the population subgroups described above is of
low incidence in the general population. This fact makes the KN web-enabled methodology ideal
for completing survey interviews.
To comply with the Government Paperwork Elimination Act (GPEA), the data collection is
currently available for completion electronically, as described above. The data collection does
not require a signature from respondents.
Efforts to Identify Duplication
This information collection does not duplicate any other effort and the information cannot be
obtained from any other source. The research firm, Lake Research Partners, has conducted
numerous studies in the area of children’s health insurance for more than a decade, and the data
collection for which we seek clearance builds on but does not duplicate these previous efforts.
Previous studies conducted by Lake Research include: a 2000 survey for the Kaiser Family
Foundation of low-income adults with children either enrolled in CHIP or Medicaid programs or
those who were eligible but not enrolled; a scan for Kaiser Family Foundation of all State
marketing and outreach materials for SCHIP in 2000, which resulted in the report Marketing
Medicaid and CHIP: A Study of State Advertising Campaigns; a series of projects around
barriers to enrollment in CHIP for the Robert Wood Johnson Foundation's Covering Kids &
Families initiative; and, a seven-State survey and a series of focus groups for the National
Academy for State Health Policy (NASHP) to understand why eligible children were not
renewing enrollment in CHIP and Medicaid.
Impact on Small Business or Other Small Entities
The information collection request does not involve any small businesses.
Consequences of Collecting Information Less Frequently
Because one of the objectives of the data collection is to monitor awareness of outreach
activities, we intend to implement three waves of the survey over the three-year period of the
authorization. Less frequent information collection will not support the analysis of changes in
target audience knowledge and awareness of CHIP. This will have an impact on the effectiveness
of outreach and communications with the target audience.
Special Circumstances Relating to Guidelines of 5 CFR 1320
There are no special circumstances with this ICR.

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Comments in Response to the Federal Register Notice and Efforts to
Consult Outside the Agency
A 60-day Federal Register notice will be published on May18, 2010, and it is attached as
Attachment 2.
The Agency has consulted with the following people regarding this information collection:
Michael Perry
Partner
Lake Research Partners
1726 M St., NW, Suite 1100
Washington, DC 20036
Email: [email protected]
Telephone: 202-776-9066
J. Michael Dennis
Executive Vice President, Government and Academic Research
Knowledge Networks, Inc
1350 Willow Road, Suite 102

Menlo Park, CA 94025
Email: [email protected]
Telephone: 650-289-2160
Explanation of Any Payments or Gifts to Respondents
Participants in the KN panel receive points for taking surveys, and receive payment after
accumulating a certain number of points. The payment for completing any given survey is
approximately $1.
Assurance of Confidentiality Provided to Respondents
All information obtained through the surveys will be reported in aggregate. No individual
respondent’s information will be reported independently or with identifying information. We will
request home address zip codes so we can match respondents to the geographic areas in which
the communication activities are being concentrated. No personal identifiers will be linked to
data or provided to CMS. All data collection instruments will be located in locked file cabinets
or on password protected computers, and accessible only by contractor project staff. All
identifying information will be removed from analytic files and will be destroyed after the
aggregated information is assembled.
In addition, all contract staff members working on the project and having access to the data are
required to sign a confidentiality agreement. See Attachment 3.

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Justification for Sensitive Questions
There are no questions of a sensitive nature on the survey. In addition, participation in the
research is voluntary, no persons are required to respond to the requests for participation, and
respondents may decline to answer any question in the studies.
Estimates of Annualized Burden Hours and Costs
Hours
Estimated response burden hours for respondents for each of the three data collections are shown
in Table 2. The total burden hours requested is 3,700 over a three-year period.
Table 2. Survey Estimates of Burden Hours

Screening
Main interviews
Total

Number of
respondents

Average # of
responses per
respondent

Average burden
per response

Total burden
hours

3,700
1,850

1
1

5/60
30/60

308.33
925
1,233.33

Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers
There is no capital cost associated with this information collection request.
Estimates of Annualized Costs to the Federal Government
The total annual cost to the Federal Government is estimated at $406,093.16 for each of the three
years of the term of the clearance. This estimate includes data collection, analysis and reporting
costs, and the cost of federal employees involved in project oversight.
CMS estimates the following costs annually in setting up testing environments and collecting,
analyzing and summarizing data:
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•
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OMB preparation: $13,968.83
Work plan: $9,215.08
Conference calls for team discussions: $19,526.92
Sampling plan: $8,367.25
Draft survey: $9,732.09
Final survey: $3,453.80
Translation: $4,744.60
Data collection: $246,804.27
Banner plan: $10,093.57
Topline report: $14,900.95
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•
•
•

Summary report: $29,670.95
Briefings: $9,614.84
Government employee oversight: $26,000

Estimated Annualized Cost to Government: $406,093.16
Explanation for Program Changes or Adjustments
This is a new collection of information.
Plans for Tabulation and Publication and Project Times Schedule
For this period of data collection, the survey will be fielded once a year for three years and will
focus on changes between previous survey waves in awareness, knowledge and satisfaction of
CHIP, awareness of outreach activities, information on health behaviors, heath care utilization
and quality of health care, and sources of information for the CHIP audience. After each wave of
the survey, the CHIP survey will be analyzed to assess whether there has been an increase in
knowledge and awareness. Survey results will be fully reported to CMS, to guide
communications materials. It is possible that some survey results will be shared through
conferences or other publications.
The schedule for information collection and dissemination of the data is from date of OMB
approval. The data collection will be completed within nine weeks of OMB approval, and the
final report will be completed within six weeks of the completion of the data collection.
Reason Display of OMB Expiration Date is Inappropriate
This research will display the expiration date for OMB approval of the information collection
and does not seek a waiver.
Exceptions to Certification for Paperwork Reduction Act Submissions
The proposed data collection does not involve any exceptions to the certification statement
identified in line 19 of OMB form 83-I.

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Statement B: Collections of Information Employing Statistical Methods
Respondent Universe and Sampling
An estimated 38 percent of families in the U.S. are at or below 250 percent of the federal poverty
level (FPL), based on data from the Bureau of Census
(http://www.census.gov/hhes/www/cpstables/032009/pov/new01_250_01.htm). As described on
page 4 of this ICR, the estimated natural distribution of completed interviews by insurance status
in this population is based on 2008 and 2009 CPS and CBO estimates, and is summarized in
Table 1. As previously described, we will have subsample sizes of n=600 across insurance
categories to allow for segmentation and regression analyses within each of these subsamples,
and for general consistency on reporting data. Among the 1,850 respondents, n=600 interviews
will be conducted among a representative sample of the Latino-eligible population. The
population we are sampling is low-income and somewhat difficult to reach so we are anticipating
a relatively low incidence rate of about twenty-five percent.
The data collection will be fielded using the KN panel. KN panel members are randomly
recruited by telephone and mail surveys, and households are provided with access to the Internet
and hardware if needed. Unlike other Internet research panels that sample only individuals with
Internet access, the KN panel is based on a sampling frame that includes both listed and unlisted
telephone numbers, as well as those without a landline telephone. The panel is not limited to
current Internet users or computer owners. In addition, the panel does not accept self-selected
volunteers.
KN panel recruitment methodology uses the same or similar quality standards established by
selected RDD surveys and area probability surveys conducted for the Federal Government (such
as the CDC-sponsored National Immunization Survey).
In 2009, KN added address-based sample (ABS) frame to supplement the RDD frame in
response to the growing number of cell-phone only households. ABS involves probability-based
sampling of addresses from the U.S. Postal Service’s Delivery Sequence File. Randomly
sampled addresses are invited to join the KN panel through a series of mailings and in some
cases telephone refusal conversion calls when a telephone number can be matched to the
sampled address. Invited households can join the panel by one of several means: by completing
and mailing back a paper form in a postage-paid envelope; by calling a toll-free hotline
maintained by Knowledge Networks; or by going to a designated KN Web site and completing
the recruitment form at the website. After initially accepting the invitation to join the panel,
respondents are then profiled for demographics and maintained on the panel using the same
procedures established for the RDD-recruited research subjects. Respondents sampled from the
RDD and ABS frames are provided the same privacy terms and confidentiality protections.
For the RDD-based sampling, KN utilizes list-assisted RDD sampling techniques on the sample
frame consisting of the entire U.S. residential telephone population. KN excludes only those
banks of telephone numbers (each consisting of 100 telephone numbers) that have zero or one
directory-listed phone numbers. Two strata are defined using 2000 Census Decennial Census
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data that has been appended to all telephone exchanges. The first stratum has a higher
concentration of Black and Hispanic households and the second stratum has a lower
concentration of these groups relative to the national estimates. KN telephone numbers are
selected with equal probability of selection for each number within each of the two strata, with
the higher concentration Black and Hispanic stratum being sampled at approximately twice the
rate of the other stratum. The sampling is done without replacement to ensure that numbers
already fielded by Knowledge Networks do not get fielded again.
In addition to the above-documented English-based panel recruitment, the KN Latino panel
provides a representative sample of the U.S. Hispanic community. The sample for the Latino
panel is recruited by a hybrid telephone recruitment design, based on a random-digit dialing
sample of U.S. Latinos and Hispanic-surname sample. It is a geographically balanced sample
that covers areas that when aggregated encompass approximately 93 percent of the nation’s 45.5
million Latinos.
Procedures for Data Collection
As previously mentioned, we will survey 1,850 parents or guardians in low-income households
(at or below 250 percent of Federal Poverty Level), of which 600 will be parents or guardians in
the Latino-eligible population. This population will be recruited through the KN panel, as
described above. KN will determine eligibility for the survey based on demographic
characteristics already collected in its database, as well as a brief screening survey.
We will use a questionnaire that has been developed specifically for the target audience. The
questionnaire will be approximately 20 minutes in length.
Data cleaning will take place throughout the data collection period with a final round of data
cleaning to occur after the last interviews have been completed. The final clean data will be
weighted to account for sample selection and non-response.
Maximizing Response Rates
The KN in-panel survey completion rates for projects of this type range from 60-80 percent,
depending to some extent on the particular subpopulation groups being included in the survey as
well as the incentive structure and reminder mechanisms.
The KN panel is a large statistically representative panel of people for whom various
demographic and socio-economic data have already been gathered. These data are particularly
useful for pre-identifying population subgroups for use in research projects on low-incidence
populations such as this one. It also should be noted that this project is not designed to influence
policy. Rather, this is a research project designed to assess how certain messages resonate with
separate and distinct low-incidence population subgroups.
This study focuses on four very unique sample groups. These groups (with their associated
number of planned completed interviews) are the following:
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•
•
•
•

Parents with minors on CHIP or Medicaid insurance (n=600 completed interviews)
Parents with minors not currently insured or else had an interruption in health insurance
in past 12 months (n=600 completed interviews)
Parents with minors on employer-sponsored insurance (n=600 completed interviews)
Parents with minors who have other forms of insurance such as individual insurance or
other types of public insurance (n=50 completed interviews)

Of these 1,850 interviews, approximately 600 interviews will be conducted with households that
are Latino.
A primary goal of this project is to meet the targeted number of interviews for the vulnerable
group of parents having minors who either do not have health insurance or else have not had
health insurance recently. Each of the population subgroups described above is of low incidence
in the general population. This fact, coupled with the survey content focusing on testing various
CMS messages involving choice/trade-off exercises, makes the KN web-enabled methodology
ideal for completing survey interviews. The vulnerable, hard-to-reach population for this study is
defined as either being currently uninsured or insured in the past year.
After data collection is complete, the data will be weighted to adjust for sampling probability and
the effects of non-response.
Test of Procedures
KN’s pre-test will involve nine cases selected from the population segments involved in this
study. The pre-test will accomplish at least three purposes. First, the pre-test will assess the
operational feasibility of the programmed survey instrument for this project using cases eligible
for this study. Second, the pre-test will also assess the length of the survey interview to see if it
concurs with the budgeted length. Finally, the pre-test will seek to identify any cognitive issues
pertaining to specific questions in the survey instrument prior to fielding the full survey. Pre-test
results will be shared and discussed with the client before fielding the full survey.
Contacts on Statistical Methods
Frank Funderburk
Center for Medicare & Medicaid Services
CMS/OEA/SRCMG/DR
7500 Security Blvd.
Baltimore, MD 21244
410-786-1820
[email protected]

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J. Michael Dennis
Executive Vice President, Government and Academic Research
Knowledge Networks, Inc
[email protected]
650-289-2160
Contact:
Christopher Koepke, Ph.D
Director of the Strategic Research and Campaign Management Group, Office of External Affairs
[email protected]
410-786-5877

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