Minimum Data Set for Medicaid Incentives for Prevention of Chronic Diseases Program Grantees

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10444 Minimum Data Set WI	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set TX	Form and Instruction	New	Repair queued
Form CMS-10444 Minimum Data Set NY	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set NV	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set NH	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set MN	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set HI	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set MT	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set CT	Form and Instruction	New	Available
Form CMS-10444 Minimum Data Set CA	Form and Instruction	New	Available
Supporting Statement - Part B_MIPCD_v2_508.doc	Supporting Statement B	Uploaded 2012-10-19	Available
Response to Public Comments for CMS-10444.docx	Supplementary Document	Uploaded 2012-10-16	Available
CMS-10444 Supporting Statement A clean copy.doc	Supporting Statement A	Uploaded 2012-11-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Instruction	New
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set WI
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set TX
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set NY
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set NV
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set NH
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set MN
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set HI
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set MT
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set CT
204547	MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction	New	Minimum Data Set CA

ICR Details

OMB Control No: 0938-1184	ICR Reference No: 201210-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Minimum Data Set for Medicaid Incentives for Prevention of Chronic Diseases Program Grantees
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: 12/21/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/22/2012
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	40	0	0
Time Burden (Hours)	3,467	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) program provides grants to states to implement programs that provide incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. The proposed information collection, the MIPCD Minimum Data Set (MDS), is intended to collect data for program performance monitoring and evaluation. The MDS is a secondary data collection that assembles information already collected by grantees in the course of tracking beneficiary participation and outcomes and performing their own evaluation activities.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47851	08/10/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 64343	10/19/2012
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444, CMS-10444	Minimum Data Set CA ,   Minimum Data Set CT ,   Minimum Data Set MT ,   Minimum Data Set HI ,   Minimum Data Set MN ,   Minimum Data Set NH ,   Minimum Data Set NV ,   Minimum Data Set NY ,   Minimum Data Set TX ,   Minimum Data Set WI

---

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	40	0	40	0	0	0
Annual Time Burden (Hours)	3,467	0	3,467	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 collection.

---

Annual Cost to Federal Government: $214,314

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]? Yes

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

---

Common Form ICR:  No

---

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: 10/22/2012

---