Community First Choice Option Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10462 Discussion Protocol for Stakeholder Focus Group	Form	New	Available
Form CMS-10462 Discussion Protocol for Beneficiary Focus Group	Form	New	Available
Form CMS-10462 Discussion Protocol for Stakeholder Focus Group	Form	New	Available
Form CMS-10462 Discussion Protocol for HCBS Provider Focus Group	Form	New	Available
Form CMS-10462 Discussion Protocol for Stakeholder Focus Group	Form	New	Available
Form CMS-10462 Non-CFC State Discussion Guide	Form	New	Available
Form CMS-10462 Community First Choice State Discussion Protocol	Form	New	Available
Supporting Statement - Part B - CFC Evaluation 20130917 gwt.doc	Supporting Statement B	Uploaded 2014-03-31	Available
CMS-10462 - Supporting Statement A [rev 3-27-2014 by OSORA PRA].docx	Supporting Statement A	Uploaded 2014-03-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
211014	Discussion Protocols for Beneficiary Focus Group and Stakeholder Focus Group	Form	New	Discussion Protocol for Stakeholder Focus Group
211014	Discussion Protocols for Beneficiary Focus Group and Stakeholder Focus Group	Form	New	Discussion Protocol for Beneficiary Focus Group
211013	Discussion Protocols for HCBS Provider Focus Group and Stakeholder Focus Group	Form	New	Discussion Protocol for Stakeholder Focus Group
211013	Discussion Protocols for HCBS Provider Focus Group and Stakeholder Focus Group	Form	New	Discussion Protocol for HCBS Provider Focus Group
211012	State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	Form	New	Discussion Protocol for Stakeholder Focus Group
211012	State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	Form	New	Non-CFC State Discussion Guide
211012	State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	Form	New	Community First Choice State Discussion Protocol

ICR Details

OMB Control No: 0938-1238	ICR Reference No: 201403-0938-017
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 21636
Title: Community First Choice Option Evaluation
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: 05/07/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/31/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	36 Months From Approved
Responses	108	0	0
Time Burden (Hours)	225	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This project is an evaluation of the implementation and progress of the Community First Choice (CFC) Option. The results of the study will be used to inform the Final Report to Congress, to be delivered by the Secretary of Health and Human Services to Congress in 2015. The project is designed to assist CMS and Congress in their understanding of States' CFC implementation plans, of the effectiveness of the CFC Option on individuals receiving home- and community-based attendant care, and on States' spending on long-term services and supports.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2401 Name of Law: Patient Protection and Affordable Care Act: Medicaid Program; Community First Choice Option
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2401 Name of Law: Patient Protection and Affordable Care Act: Medicaid Program; Community First Choice Option

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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:
	79 FR 3207	01/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 16337	03/25/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Discussion Protocols for Beneficiary Focus Group and Stakeholder Focus Group	CMS-10462, CMS-10462	Discussion Protocol for Beneficiary Focus Group ,   Discussion Protocol for Stakeholder Focus Group
Discussion Protocols for HCBS Provider Focus Group and Stakeholder Focus Group	CMS-10462, CMS-10462	Discussion Protocol for HCBS Provider Focus Group ,   Discussion Protocol for Stakeholder Focus Group
State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	CMS-10462, CMS-10462, CMS-10462	Community First Choice State Discussion Protocol ,   Non-CFC State Discussion Guide ,   Discussion Protocol for Stakeholder Focus Group

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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	108	0	108	0	0	0
Annual Time Burden (Hours)	225	0	225	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: Not applicable. This is a new collection.

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Annual Cost to Federal Government: $219,878

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: 03/31/2014

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