Evaluation of the Multi-Payer Advance Primary Care Practice (MAPCP) Demonstration: Conduct Beneficiary Experience with Care Surveys

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10483 Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Interview Protocols	Form and Instruction	New	Available
PCMCH_SSB_02122013.pdf	Supporting Statement B	Uploaded 2013-09-03	Available
PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3 0_SPA.pdf	Supplementary Document	Uploaded 2013-09-03	Available
PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3.0.pdf	Supplementary Document	Uploaded 2013-09-03	Available
PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0_SPA.pdf	Supplementary Document	Uploaded 2013-09-03	Available
PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0.pdf	Supplementary Document	Uploaded 2013-09-03	Available
CMS-10483 Supporting Statement A.docx	Supporting Statement A	Uploaded 2013-09-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208578	Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Interview Protocols	Form and Instruction	New

ICR Details

OMB Control No: 0938-1223	ICR Reference No: 201309-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 20467
Title: Evaluation of the Multi-Payer Advance Primary Care Practice (MAPCP) Demonstration: Conduct Beneficiary Experience with Care Surveys
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 without change	Conclusion Date: 02/26/2014
	Date Received in OIRA: 09/10/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	10,038	0	0
Time Burden (Hours)	3,313	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration was announced by Secretary Kathleen Sebelius in September 2009 to allow Medicare to join state Medicaid programs and private insurers in participating states to improve the delivery of primary care. CMS selected eight states to participate in this demonstration: Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan, and Minnesota. CMS is conducting an evaluation of the demonstration to assess the effects of advanced primary care practice when supported by Medicare, Medicaid, and private health plans. To carry out one component of this effort, we seek OMB approval to administer the PCMH-CAHPS Survey in those states participating in the MAPCP Demonstration. In those states we will conduct one round of surveys in 2014 of Medicare and Medicaid beneficiaries.

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Authorizing Statute(s): None

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:
	78 FR 2659	05/31/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 48686	08/09/2013
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
Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Interview Protocols	CMS-10483, CMS-10483	Medical Home Survey ,   Medical Home Survey - Spanish version

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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	10,038	0	0	10,038	0	0
Annual Time Burden (Hours)	3,313	0	0	3,313	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: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $551,543

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: 09/10/2013

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