Medicare Current Beneficiary Survey (MCBS)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-P0015A MCBS Round 73 Questionnaires	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section KN_05.01.0002	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section IN_12.01.0000	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section IA_08.01.0000	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section HIS_13.01.0001	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section HI_17.01.0002	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section HF_10.01.0002	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section ENS_10.01.0001	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Section by Section CPS_16.01.0002	Form and Instruction	Unchanged	Available
Form CMS-P0015A Spanish Showcars KN-Sp	Form and Instruction	Unchanged	Available
Form CMS-P0015A English Showcards HI-Eng	Form and Instruction	Unchanged	Available
Form CMS-P0015A Spanish Folder General Specifications Spanish Text_19.01.001	Form and Instruction	Unchanged	Available
Form CMS-P0015A General Specifications Spanish Text_19.01.001	Form and Instruction	Unchanged	Available
Form CMS-P0015A General Specifications Screen Types_19.01.0001	Form and Instruction	Unchanged	Available
Form CMS-P0015A MCBS Household Round 67 Instruments	Form and Instruction	Unchanged	Repair queued
Form CMS-P0015A Attachment 8 - Verification Re-interview	Form and Instruction	Unchanged	Repair queued
Form CMS-P0015A Attachment 6 - MCBS Faclility Round 64 Instruments	Form and Instruction	Unchanged	Repair queued
Form CMS-P-0015A Attachment 5 - Facility Screener	Form and Instruction	Unchanged	Available
Attachment B - R75 PVQ (JAN 2016).pdf	Supplementary Document	Uploaded 2016-01-15	Available
Attachment A - R75 IAQ (JAN 2016).pdf	Supplementary Document	Uploaded 2016-01-15	Available
0938-0568 - MCBS Nonsubstantive change request_R75 (JAN 2016).doc	Justification for No Material/Nonsubstantive Change	Uploaded 2016-01-15	Available
Attachment C - R74 Medical Provider Terminology (Sept 2015).pdf	Supplementary Document	Uploaded 2015-09-24	Available
Attachment B - R74 KNQ (Sept 2015).pdf	Supplementary Document	Uploaded 2015-09-24	Available
Attachment A - R74 PVQ (Sept 2015).pdf	Supplementary Document	Uploaded 2015-09-24	Available
MCBS Nonsubstantive change request (Sept 2015).doc	Justification for No Material/Nonsubstantive Change	Uploaded 2015-09-24	Available
Attachment D - R73 USQ PPIC PAQ.pdf	Supplementary Document	Uploaded 2015-06-24	Available
Attachment C - R73 IAQ.pdf	Supplementary Document	Uploaded 2015-06-24	Available
Attachment B - R73 HFQ.pdf	Supplementary Document	Uploaded 2015-06-24	Available
Attachment A - R73 DUQ.pdf	Supplementary Document	Uploaded 2015-06-24	Available
MCBS Nonsubstantive change request.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2015-06-24	Available
MCBS Supporting Statement - Part B.pdf	Supporting Statement B	Uploaded 2013-10-25	Available
attachment10.pdf	Supplementary Document	Uploaded 2013-10-25	Available
attachment09.pdf	Supplementary Document	Uploaded 2013-10-25	Available
attachment07.pdf	Supplementary Document	Uploaded 2013-10-25	Available
Attachment 3.zip	Supplementary Document	Uploaded 2013-10-25	Repair queued
attachment 2.zip	Supplementary Document	Uploaded 2013-10-25	Available
Attachments TOC.pdf	Supplementary Document	Uploaded 2013-10-25	Available
CMS-P-0015A Final Supporting Statement - Part A.docx	Supporting Statement A	Uploaded 2013-10-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	MCBS Round 73 Questionnaires
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section KN_05.01.0002
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section IN_12.01.0000
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section IA_08.01.0000
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section HIS_13.01.0001
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section HI_17.01.0002
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section HF_10.01.0002
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section ENS_10.01.0001
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Section by Section CPS_16.01.0002
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	Spanish Showcars KN-Sp
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	English Showcards HI-Eng
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	Spanish Folder General Specifications Spanish Text_19.01.001
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	General Specifications Spanish Text_19.01.001
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	General Specifications Screen Types_19.01.0001
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	MCBS Household Round 67 Instruments
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	Attachment 8 - Verification Re-interview
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	Attachment 6 - MCBS Faclility Round 64 Instruments
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Unchanged	Attachment 5 - Facility Screener

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 201601-0938-001
Status: Historical Active	Previous ICR Reference No: 201509-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: 20757
Title: Medicare Current Beneficiary Survey (MCBS)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/10/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/15/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	07/31/2017	07/31/2017
Responses	49,650	0	49,650
Time Burden (Hours)	58,450	0	58,450
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries. The core of the MCBS is a series of interviews with a stratified random sample of the Medicare population, including aged and disabled enrollees, residing in the community or in institutions. Questions are asked about enrollees' patterns of health care use, charges, insurance coverage, and payments over time. Respondents are asked about their sources of health care coverage and payment, their demographic characteristics, their health and work history, and their family living circumstances. In addition to collecting information through the core questionnaire, the MCBS collects information on special topics through supplements. For example, questions are asked about enrollees' income and assets, access to health care, health and functional status and satisfaction with care. Special supplements also focus on emerging trends in health care.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(b)(1) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
  

Citations for New Statutory Requirements: None

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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 45205	07/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P-0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A, CMS-P0015A	Attachment 5 - Facility Screener ,   Attachment 6 - MCBS Faclility Round 64 Instruments ,   Attachment 8 - Verification Re-interview ,   MCBS Household Round 67 Instruments ,   General Specifications Screen Types_19.01.0001 ,   General Specifications Spanish Text_19.01.001 ,   Spanish Folder General Specifications Spanish Text_19.01.001 ,   English Showcards HI-Eng ,   Spanish Showcars KN-Sp ,   English Section by Section CPS_16.01.0002 ,   English Section by Section ENS_10.01.0001 ,   English Section by Section HF_10.01.0002 ,   English Section by Section HI_17.01.0002 ,   English Section by Section HIS_13.01.0001 ,   English Section by Section IA_08.01.0000 ,   English Section by Section IN_12.01.0000 ,   English Section by Section KN_05.01.0002 ,   English Section by Section ,   English Section by Section ,   English Section by Section ,   English Section by Section ,   English Section by Section ,   English Section by Section ,   MCBS Round 73 Questionnaires

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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	49,650	49,650	0	0	0	0
Annual Time Burden (Hours)	58,450	58,450	0	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:

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Annual Cost to Federal Government: $17,158,000

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: 01/15/2016

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