Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10615 Debriefing Script - New Enrollee Survey	Form and Instruction	New	Available
Form CMS-10615 New Enrollee Survey	Form	New	Available
Form CMS-10615 Enrollee Survey	Form	New	Available
Form CMS-10615 Disenrollee Lockout Survey	Form	New	Available
Form CMS-10615 Debriefing Script - Enrollee Survey	Form and Instruction	New	Available
Form CMS-10615 Debriefing Script - Disenrolelee Lockout Survey	Form and Instruction	New	Available
Form CMS-10615 Consent Form	Form	New	Repair queued
Form CMS-10615 Debriefing Script - Alternate Policy Survey Questions	Form and Instruction	New	Available
Form CMS-10615 Alternate Policy Survey Question	Form	New	Available
CMS-10615 Emergency Justification (signed by CMS Administrator).pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2016-03-21	Available
CMS-10615 - Supporting Statement A [rev 3-18-2016 by OSORA PRA].doc	Supporting Statement A	Uploaded 2016-03-18	Available
CMS-10615 Emergency Justification.docx	Supplementary Document	Uploaded 2016-03-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form and Instruction	New	Debriefing Script - New Enrollee Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form	New	New Enrollee Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form	New	Enrollee Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form	New	Disenrollee Lockout Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form and Instruction	New	Debriefing Script - Enrollee Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form and Instruction	New	Debriefing Script - Disenrolelee Lockout Survey
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form	New	Consent Form
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form and Instruction	New	Debriefing Script - Alternate Policy Survey Questions
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form	New	Alternate Policy Survey Question
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Other-Recruitment Script	New

ICR Details

OMB Control No: 0938-1300	ICR Reference No: 201603-0938-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/18/2016
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/21/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/18/2016
Terms of Clearance: We approve this emergency Paperwork Reduction Act approval request with the understanding that: notice of Federal Customer Satisfaction Survey Instrument Testing will be published in the Federal Register; CMS will accept public comments on the draft instruments simultaneously with testing; CMS will submit final, OMB-approved debriefing scripts into ROCIS no later than March 25, 2016; an additional 30 day comment period will be provided after instrument testing, but prior to the implementation phase of this effort. We appreciate CMS’ agreement to these terms of clearance, as well as the understanding that CMS will consider and respond to public comments in the separate submission of a request for emergency approval of the Federal Customer Satisfaction Survey implementation effort.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	6 Months From Approved
Responses	36	0	0
Time Burden (Hours)	36	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected will be used to ensure that the survey instruments can be tested, revised, and finalized in enough time to allow: Indiana and public comment, submission and OMB approval of the main study package, survey data collection and analysis, and CMS deliberation regarding the waiver prior to its December 1, 2016 expiration date.

Emergency Justfication: See attached.

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Authorizing Statute(s): US Code: 42 USC 1315 Name of Law: Social Security 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

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
Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615	Alternate Policy Survey Question ,   Debriefing Script - Alternate Policy Survey Questions ,   Consent Form ,   Debriefing Script - Disenrolelee Lockout Survey ,   Debriefing Script - Enrollee Survey ,   Disenrollee Lockout Survey ,   Enrollee Survey ,   New Enrollee Survey ,   Debriefing Script - New Enrollee Survey

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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	36	0	0	36	0	0
Annual Time Burden (Hours)	36	0	0	36	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: Not applicable. This is a new collection.

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Annual Cost to Federal Government: $31,118

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 03/18/2016

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