Medicare Beneficiary and Family-Centered Satisfaction Survey

Forms and Documents

Document Name	Status
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey Form	Modified
CMS-10393 Revised PRA Supporting Stmt-Pt B Passback Clean Final 07 14 2016.docx Supporting Statement B	2016-07-19
CMS-10393 Final Supporting Stmt-Pt A Passback Clean Final 07 14 2016.docx Supporting Statement A	2016-07-19
Revised Bene Survey Letter_followup_clean version.docx Supplementary Document	2013-04-30
Revised Bene Survey Intro Letter_clean version.docx Supplementary Document	2013-04-30

IC Document Collections

IC ID	Document Title	Status
201543	Medicare Beneficiary and Family-Centered Satisfaction Survey Form	Modified

ICR Details

OMB Control No: 0938-1177	ICR Reference No: 201509-0938-012
Status: Historical Active	Previous ICR Reference No: 201305-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 19423
Title: Medicare Beneficiary and Family-Centered Satisfaction Survey
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/26/2016
	Date Received in OIRA: 09/25/2015
Terms of Clearance: Pursuant to 5 CFR 1320, on the condition that all required data collection instruments associated with the information collection request display OMB control number and current expiration date, the information collection is approved for three (3) years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	16,010	0	68,000
Time Burden (Hours)	4,003	0	17,000
Cost Burden (Dollars)	20,013	0	85,000

---

Abstract: The data collection methodology used for the Beneficiary Satisfaction will be conducted primarily via mail. A mail-based methodology will achieve the goals of being efficient, effective, and minimally burdensome for beneficiary respondents. A mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Using the 3-step mail approach described above, we anticipate that data collection would occur over an 8 to 10 weeks. This is to say, if the first survey mailing were dropped on January 1, we would anticipate completing data collection at the end of February or early March. Data would then be cleaned, scores would be generated, and data would be delivered to CMS. As previously described, we anticipate that a mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we would recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Through the pilot test, we will determine the response rate that can be achieved using this approach. If it is deemed necessary, additional mailout reminders can be added to the protocol, or a telephone non-response step can be added to the protocol. Using the 3-step mail approach described above, we anticipate that data collection would occur over an 8 to 10 weeks.

---

Authorizing Statute(s): US Code: 42 USC 1320c Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: None

---

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:
	80 FR 43091	07/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57821	09/25/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393, CMS-10393, CMS-10393, CMS-10393	Bene Appeals Survey ,   Beneficiary Appeals Survey ,   Beneficiary Complaint Survey ,   Bene Complaint Survey

---

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	16,010	68,000	0	-51,990	0	0
Annual Time Burden (Hours)	4,003	17,000	0	-12,997	0	0
Annual Cost Burden (Dollars)	20,013	85,000	0	-64,987	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There was an error in the numbers. Previous numbers reflected 3 year numbers instead of annual numbers in the "ICR Summary of Burden"

---

Annual Cost to Federal Government: $997,000

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]? 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

---

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: 09/25/2015

---