Analysis of Transportation Barriers to Utilization of Medicare Services by American Indian and Alaska Native Medicare Beneficiaries

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10399 Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS	Form and Instruction	New	Available
Form CMS-10399 Appendix G CMS Consent Forms	Form and Instruction	New	Available
Form CMS-10399 Appendix E Beneficiaries and Family Members Focus Group Protocol	Form and Instruction	New	Available
Form CMS-10399 Appendix D Beneficiaries and Family Members Demographic Survey	Form and Instruction	New	Available
Form CMS-10399 Appendix F Providers Interview Protocol	Form and Instruction	New	Available
Form CMS-10399 Appendix C Beneficiary Interview Protocol	Form and Instruction	New	Available
Form CMS-10399 Appendix A BENEFICIARY TBS	Form and Instruction	New	Available
Form CMS-10399 Appendix B PROVIDERS TBS	Form and Instruction	New	Available
CMS-10399 Supporting Statement Part B v5 CLEAN_rev10-15-12.pdf	Supporting Statement B	Uploaded 2012-11-15	Available
CMS Transportation Barriers Crosswalk.pdf	Supplementary Document	Uploaded 2012-04-19	Available
CMS-10399 Supporting Statement Part A v5 CLEAN_rev_10-15-12.pdf	Supporting Statement A	Uploaded 2012-11-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202089	Survey	Form and Instruction	New	Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS
202089	Survey	Form and Instruction	New	Appendix G CMS Consent Forms
202089	Survey	Form and Instruction	New	Appendix E Beneficiaries and Family Members Focus Group Protocol
202089	Survey	Form and Instruction	New	Appendix D Beneficiaries and Family Members Demographic Survey
202089	Survey	Form and Instruction	New	Appendix F Providers Interview Protocol
202089	Survey	Form and Instruction	New	Appendix C Beneficiary Interview Protocol
202089	Survey	Form and Instruction	New	Appendix A BENEFICIARY TBS
202089	Survey	Form and Instruction	New	Appendix B PROVIDERS TBS

ICR Details

OMB Control No: 0938-1182	ICR Reference No: 201204-0938-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Analysis of Transportation Barriers to Utilization of Medicare Services by American Indian and Alaska Native Medicare Beneficiaries
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 with change	Conclusion Date: 12/11/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/26/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved
Responses	3,418	0	0
Time Burden (Hours)	2,544	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the proposed study is to identify and analyze transportation barriers associated with the utilization of Medicare services by American Indian and Alaska Native (AI/AN) beneficiaries, to identify and analyze the health outcomes resulting from those barriers, and ultimately to identify potential solutions that could help mitigate the problem and produce meaningful improvements in health care use and health outcomes for this population. Specifically, the information that will be collected through the use of instruments and the study developed under the Analysis of Transportation Barriers to Utilization of Medicare Services by American Indian and Alaska Native Medicare Beneficiaries Project has not been collected or evaluated previously by any agency or individual, so data on the extent of transportation barriers for rural AI/AN beneficiaries to Medicare services by AI/AN Medicare beneficiaries are not available except from the proposed data collection activity. The information gathered as part of the project --through the use of survey, interview, and focus group instruments--will be used by CMS to identify transportation barriers to Medicare services for AI/AN Medicare beneficiaries. It will provide the first ever complete evaluation of transportation barriers to health care for this population.

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Authorizing Statute(s): PL: Pub.L. 94 - 437 Title IV Name of Law: Access to Health Care
  

Citations for New Statutory Requirements: PL: Pub.L. 94 - 437 Title IV Name of Law: Access to Health Care

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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 38655	07/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 23265	04/18/2012
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
Survey	CMS-10399, CMS-10399, CMS-10399, CMS-10399, CMS-10399, CMS-10399, CMS-10399, CMS-10399	Appendix B PROVIDERS TBS ,   Appendix A BENEFICIARY TBS ,   Appendix C Beneficiary Interview Protocol ,   Appendix F Providers Interview Protocol ,   Appendix D Beneficiaries and Family Members Demographic Survey ,   Appendix E Beneficiaries and Family Members Focus Group Protocol ,   Appendix G CMS Consent Forms ,   Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS

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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	3,418	0	3,418	0	0	0
Annual Time Burden (Hours)	2,544	0	2,544	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: This is a new information collection request.

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Annual Cost to Federal Government: $698,572

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: 04/26/2012

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