Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid (CMS-10493)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10493 State Burden	Form and Instruction	Modified	Available
Form CMS-10493 Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Form and Instruction	Unchanged	Available
Attachment 1. Methods and Findings for Pilot Study 04-21-14 (clean).docx	Supplementary Document	Uploaded 2014-04-28	Available
CMS-10493 - Supporting B rev 04-21-2013 (clean).docx	Supporting Statement B	Uploaded 2014-04-28	Available
CMS-10493 - Supporting A rev 04-21-2014 (clean).docx	Supporting Statement A	Uploaded 2014-04-28	Available
11 19 13 Amended Response to CAHPS Survey Comments.docx	Supplementary Document	Uploaded 2013-11-20	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

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209182	State Burden	Form and Instruction	Modified
209181	Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1239	ICR Reference No: 201404-0938-010
Status: Historical Active	Previous ICR Reference No: 201311-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 20823
Title: Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid (CMS-10493)
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: 05/08/2014
	Date Received in OIRA: 04/28/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved
Responses	510,051	0	0
Time Burden (Hours)	172,244	0	0
Cost Burden (Dollars)	0	0	0

---

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.

---

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

---

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

---

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)

---

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	510,051	0	510,051	0	0	0
Annual Time Burden (Hours)	172,244	0	172,244	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: $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

---

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: 04/28/2014

---