Consumer Research Supporting Outreach for Health Insurance Marketplace

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10458 SHOP Survey	Form and Instruction	New	Repair queued
Form CMS-10458 SHOP Screener	Form and Instruction	New	Available
Form CMS-10458 Individual Survey	Form and Instruction	New	Available
Form CMS-10458 Individual Screener	Form and Instruction	New	Available
CMS-10458_Supporting_Statement_Part_B (REVISED - 6-5-13).docx	Supporting Statement B	Uploaded 2013-06-13	Available
CMS-10458_Comment_Crosswalk.pdf	Supplementary Document	Uploaded 2013-04-08	Available
CMS-10458_Supporting_Statement_Part_A (REVISED - 5-31-13).docx	Supporting Statement A	Uploaded 2013-06-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206917	SHOP Survey	Form and Instruction	New
206916	SHOP Screener	Form and Instruction	New
206915	Individual Survey	Form and Instruction	New
206914	Individual Screener	Form and Instruction	New

ICR Details

OMB Control No: 0938-1203	ICR Reference No: 201305-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 19245
Title: Consumer Research Supporting Outreach for Health Insurance Marketplace
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: 06/18/2013
	Date Received in OIRA: 05/15/2013
Terms of Clearance: CMS will use the information from this ICR to identify knowledge/awareness gaps among the uninsured; the results will inform communication materials and outreach. CMS acknowledges that the study design does not allow, and thus will not be used for: a) tracking temporal trends, b) evaluating the communication campaign, or c) generating prevalence estimates about the characteristics of the uninsured population.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	40,200	0	0
Time Burden (Hours)	2,480	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Medicare and Medicaid Services is requesting clearance for two surveys to aid in understanding levels of awareness and customer service needs associated with the Health Insurance Marketplace established by the Affordable Care Act. Because the Marketplace will provide coverage to the almost 50 million uninsured in the United States through individual and small employer programs, we have developed one survey to be administered to individual consumers most likely to use the Marketplace and another to be administered to small employers most likely to use the Small Business Health Options portion of the Marketplace. These brief surveys, designed to be conducted quarterly, will give CMS the ability to obtain a rough indication of the types of outreach and marketing that will be needed to enhance awareness of and knowledge about the Marketplace for individual and business customers. CMS' biggest customer service need is likely to be providing sufficient education so consumers: a) can take advantage of the Marketplace and b) know how to access CMS' customer service channels. The surveys will provide information on media use, concept awareness, and conceptual or content areas where education for customer service delivery can be improved. Awareness and knowledge gaps are likely to change over time based not only on effectiveness of CMS' marketing efforts, but also of those of State, local, private sector, and nongovernmental organizations.

---

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

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 . 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:
	78 FR 2407	01/11/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 20320	04/04/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Individual Screener	CMS-10458	Individual Screener
Individual Survey	CMS-10458	Individual Survey
SHOP Screener	CMS-10458	SHOP Screener
SHOP Survey	CMS-10458	SHOP Survey

---

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	40,200	0	40,200	0	0	0
Annual Time Burden (Hours)	2,480	0	2,480	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.

---

Annual Cost to Federal Government: $1,644,000

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: 05/15/2013

---