Prospective Evaluation of Evidence-Based Community Wellness and Prevention Programs (CMS-10509)

Forms and Documents

Document Name	Status
Form CMS-10509 Program Participants Survey Form and Instruction	New
Form CMS-10509 National Readiness Survey Form and Instruction	New
RTC_CommunityBasedWellnessPrograms.pdf Supplementary Document	2014-09-08
8926 04 13 12 13 Expedited approval of CMS Wellness Eval.pdf Supplementary Document	2014-09-08
OMB_Draft_Wellness_Eval_Part_B_Attachment_1_Sources_of_Survey_Items_03112014.pdf Supplementary Document	2014-04-28
OMB_Wellness_Eval_Part_B_09052014_clean.docx Supporting Statement B	2014-09-08
OMB_Wellness_Eval_Part_A_09052014_clean.docx Supporting Statement A	2014-09-10

IC Document Collections

IC ID	Document Title	Status
211403	Program Participants Survey Form and Instruction	New
211401	National Readiness Survey Form and Instruction	New

ICR Details

OMB Control No: 0938-1252	ICR Reference No: 201404-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMMI
Title: Prospective Evaluation of Evidence-Based Community Wellness and Prevention Programs (CMS-10509)
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: 09/12/2014
	Date Received in OIRA: 04/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved
Responses	42,814	0	0
Time Burden (Hours)	18,825	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services (CMS) is planning to (1) assess beneficiary readiness to engage in community-based wellness and prevention activities and (2) evaluate the impacts of existing wellness programs on the health and wellbeing of participating beneficiaries and on potential cost outcomes for the Medicare program. This effort is a critical component of a larger, ongoing evaluation of wellness programs mandated by Congress in the Affordable Care Act (ACA). In Section 4202, subsection (b) of the ACA, Congress mandated that CMS conduct an evidence review and independent evaluation of wellness programs. This evaluation effort will 1) describe the overall distribution of readiness to engage with wellness programs in the Medicare population, 2) better adjust for selection biases of individual programs and interventions using beneficiary level survey data, 3) evaluate program impacts on health behaviors, self-reported health outcomes, and claims-based measures of utilization and costs, and 4) better describe program implementation, operations and cost in relation to the expected benefits.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4202 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 4202 Name of Law: 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 70059	11/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 21933	04/18/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Program Participants Survey	CMS-10509, CMS-10509	In-Depth Interview Discussion Guide with Wellness Program Staff ,   Wellness Program Participant Surveys
National Readiness Survey	CMS-10509	National Survey of Medicare Beneficiaries

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ICR Summary 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	42,814	0	0	42,814	0	0
Annual Time Burden (Hours)	18,825	0	0	18,825	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: The number of completed Participant baseline surveys has been revised based on new information about expected response rate for on-site survey delivery. The number of completed Participant 6-month followup and Disenrollee surveys has been revised based on a change in the operational design.

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Annual Cost to Federal Government: $2,576,296

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: 04/28/2014

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