Medicare Beneficiary and Family-Centered Satisfaction Survey

Forms and Documents

Document Name	Status
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey Form	Modified
Use of Satisfaction Survey Data.docx Supplementary Document	2012-09-04
Beneficiary Cognitive testing Report.docx Supplementary Document	2012-09-04
BENE_ENV_BRM (reply envelope).pdf Supplementary Document	2012-09-04
BENE_#10 (for sending reminder letter .pdf Supplementary Document	2012-09-04
Bene Survey Letter 2 (Reminder)_complaints Eng-Span.docx Supplementary Document	2012-09-04
Bene Survey Letter 2 (Reminder)_appeals Eng-Span.docx Supplementary Document	2012-09-04
Bene Survey Letter 1 Eng-Span.docx Supplementary Document	2012-09-04
Bene Letter 3 Eng-Span.docx Supplementary Document	2012-09-04
BENE 9x12 OE (sending cover letter and survey).pdf Supplementary Document	2012-09-04
Revised PRA Supporting Stmt-Pt B (082812).docx Supporting Statement B	2012-09-04
Public Comments Response-032212.docx Supplementary Document	2012-03-27
CMS Medicare Beneficiary Survey Revision Crosswalk 022912.docx Supplementary Document	2012-03-27
Revised PRA Supporting Stmt-Pt A (082812).docx Supporting Statement A	2012-09-04

IC Document Collections

IC ID	Document Title	Status
201543	Medicare Beneficiary and Family-Centered Satisfaction Survey Form	Modified

ICR Details

OMB Control No: 0938-1177	ICR Reference No: 201204-0938-001
Status: Historical Active	Previous ICR Reference No: 201203-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Beneficiary and Family-Centered Satisfaction Survey
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/25/2012
	Date Received in OIRA: 04/03/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved
Responses	68,000	0	0
Time Burden (Hours)	17,000	0	0
Cost Burden (Dollars)	85,000	0	0

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Abstract: The data collection methodology used for the Beneficiary Satisfaction flows from the proposed sampling approach. While it was feasible to conduct the 9th SOW via telephone data collection only, with a quarterly sample size for the 10th SOW estimated to be 2,664, it does not seem efficient to maintain a telephone only data collection approach. Based on recent literature on survey methodology and response rates by mode, we recommend using a data collection that is primarily mail. A mail-based methodology will achieve the goals of being efficient, effective, and minimally burdensome for beneficiary respondents. As previously described, we anticipate that a mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we would recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Through the pilot test, we will determine the response rate that can be achieved using this approach. If it is deemed necessary, additional mailout reminders can be added to the protocol, or a telephone non-response step can be added to the protocol. Using the 3-step mail approach described above, we anticipate that data collection would occur over an 8 to 10 weeks.

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Authorizing Statute(s): US Code: 42 USC 1320c Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: US Code: 42 USC 1320-c Name of Law: Functions of Peer Review Organizations

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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:
	76 FR 34076	06/10/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 14806	03/13/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393, CMS-10393	Bene Survey Appeals ,   Bene Survey Complaint

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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	68,000	0	0	0	0	68,000
Annual Time Burden (Hours)	17,000	0	0	0	0	17,000
Annual Cost Burden (Dollars)	85,000	0	0	0	0	85,000

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,024,620

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 04/03/2012

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