Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid)	Form and Instruction	New	Available
Form CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)	Form and Instruction	New	Available
Form CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid)	Form and Instruction	New	Available
Form CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)	Form and Instruction	New	Available
11 19 13 Amended Response to CAHPS Survey Comments.docx	Supplementary Document	Uploaded 2013-11-20	Available
CMS-10493 - Supporting B [rev 10-31-2013 by OSORA PRA].docx	Supporting Statement B	Uploaded 2013-11-03	Available
Projected FY 2014 Medicaid Eligible Counts of Adults.docx	Supplementary Document	Uploaded 2013-11-01	Available
Attachment B - Updates to Survey Instrument.docx	Supplementary Document	Uploaded 2013-10-31	Available
Medicaid CAHPS Survey Notification Letter.SIGNED.pdf	Supplementary Document	Uploaded 2013-11-01	Available
Medicaid CAHPS Survey Postcard.SIGNED.pdf	Supplementary Document	Uploaded 2013-11-01	Available
CMS-10493 - Supporting A [rev 10-31-2013 by OSORA PRA].docx	Supporting Statement A	Uploaded 2013-11-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209182	State Burden	Form and Instruction	New	CAHPS 5.0H Adult Questionnaire (Medicaid)
209182	State Burden	Form and Instruction	New	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)
209181	Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Form and Instruction	New	CAHPS 5.0H Adult Questionnaire (Medicaid)
209181	Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Form and Instruction	New	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)

ICR Details

OMB Control No: 0938-1239	ICR Reference No: 201311-0938-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 20823
Title: Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 12/09/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/04/2013
Terms of Clearance: CMS will resubmit this request following the completion of the pilot and will incorporate any changes resulting from the pilot in that request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In 2014, the CMS Centers for Medicare and Medicaid Services (CMCS) plans to conduct a nationwide survey of adults covered by Medicaid using the Consumer Assessment Healthcare Providers and Systems (CAHPS) survey. The survey is to understand Medicaid enrollees' experiences with care, satisfaction with care, and access to care. Collection is critical to the mission of CMS and will sample beneficiaries from four population groups consisting of disabled individuals, non-disabled individuals enrolled in managed care; non-disabled individuals with FFS provider; and individuals dully eligible for Medicare and Medicaid.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2701 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2701 Name of Law: Patient Protection and Affordable Care Act

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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 43887	07/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	CMS-10493, CMS-10493	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid) ,   CAHPS 5.0H Adult Questionnaire (Medicaid)
State Burden	CMS-10493, CMS-10493	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid) ,   CAHPS 5.0H Adult Questionnaire (Medicaid)

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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: Not applicable. This is a new collection of information.

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Annual Cost to Federal Government: $3,850,000

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

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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: 11/04/2013

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