Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10203 Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	Form and Instruction	New	Available
Attachment_10_Supporting_Statement_Part_B_REVISED_v2.docx	Supporting Statement B	Uploaded 2012-10-31	Available
Attachment_11_CMS_10203_Response_to_Public_Comments.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_8_Covariates.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_12_CMS_10203_Crosswalk.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_3_Response_Rate_Table.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_7_HOS_M_Materials_English.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_5_HOS_Materials_English_and_Spanish.pdf	Supplementary Document	Uploaded 2012-08-14	Available
Attachment_2_Publications.pdf	Supplementary Document	Uploaded 2012-08-14	Available
TOC_Revised_Package_Attachments_07252012.pdf	Supplementary Document	Uploaded 2012-08-14	Available
UPDAttachment 14 - RTI Spanish_Chinese Cognitive Testing Report Final 05-04-09.pdf	Supplementary Document	Uploaded 2010-12-22	Available
UPD Attachment 13 - 07282010 RTI English HOS cog testing report final.pdf	Supplementary Document	Uploaded 2010-12-22	Available
UPD Attachmenet 12-ud - Non-Response Bias Report_8-11-04.pdf	Supplementary Document	Uploaded 2010-12-22	Available
UPD Attachment 11 - HOS Sample Design.doc	Supplementary Document	Uploaded 2010-12-22	Available
UPD Attachment 10 - HPMS SORN Mod 01-14-2008.pdf	Supplementary Document	Uploaded 2010-12-22	Available
UPD Attachment 9 - 1998 Federal Register.docx	Supplementary Document	Uploaded 2010-12-22	Available
Attachment7c.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment7b.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment7a.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment5b.pdf	Supplementary Document	Uploaded 2010-08-25	Available
AttachmentsTOC.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment8.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment5a.pdf	Supplementary Document	Uploaded 2010-08-25	Repair queued
Attachment2.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment3.pdf	Supplementary Document	Uploaded 2010-08-25	Available
Attachment1.pdf	Supplementary Document	Uploaded 2010-08-25	Available
CMS-10203_Supporting_Statement_Part_A_REVISED attachment 9.pdf	Supporting Statement A	Uploaded 2012-08-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8327	Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)	Other-Other: Medicare HOS - Modified 2010 Questionnaire: English	Removed
203728	Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	Form and Instruction	New

ICR Details

OMB Control No: 0938-0701	ICR Reference No: 201208-0938-008
Status: Historical Active	Previous ICR Reference No: 201008-0938-023
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152
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: 11/07/2012
	Date Received in OIRA: 08/15/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2015	36 Months From Approved	01/31/2014
Responses	666,120	0	1,099,560
Time Burden (Hours)	219,820	0	366,520
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services collects quality performance measures in order to hold the Medicare managed care industry accountable for the care being delivered, to enable quality improvement, and to provide quality information to Medicare beneficiaries in order to promote an informed choice. It is critical to CMS's mission that we collect and disseminate information that can be used to help beneficiaries choose among health plans, contribute to improved quality of care through identification of improvement opportunities, and assist CMS in carrying out its oversight and purchasing responsibilities.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   US Code: 42 USC 442, Subpart D Name of Law: null
  

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:
	77 FR 47850	08/10/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25181	04/27/2012
Did the Agency receive public comments on this ICR? No

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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
Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)
Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	CMS-10203, CMS-10203	Medicare HOS 2013 Questionnaire (English) ,   Medicare HOS-Modified 2013 Questionnaire (English)

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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	666,120	1,099,560	0	-433,440	0	0
Annual Time Burden (Hours)	219,820	366,520	0	-146,700	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: Over the past five years the overall baseline response rate has fallen short of the 70% target. This is not saying that all plan by plan baseline response rates were below 70%, but that as a whole the overall baseline response rate has fallen below 70% consistently over the past five years. Drastically increasing respondent burden has adverse implications to future response rates so adjustments to the sampling methodology were developed to moderately increase the number of responses where appropriate and eliminate the burden where prudent.

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Annual Cost to Federal Government: $2,415,500

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: 08/15/2012

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