Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey, Focus Groups, and Informational Interviews (CMS-10615)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10615 2016 Interview Guide	Form and Instruction	New	Repair queued
Form CMS-10615 Participant Informed Consent	Form and Instruction	New	Available
Form CMS-10615 HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)	Form and Instruction	Modified	Available
Form CMS-10615 HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper)	Form and Instruction	Modified	Available
Form CMS-10615 HIP 2.0 Beneficiary Survey: Enrollees (paper)	Form and Instruction	Modified	Available
Form CMS-10615 HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots)	Form and Instruction	Modified	Available
Form CMS-10615 HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots)	Form and Instruction	Modified	Repair queued
Form CMS-10615 HIP 2.0 Enrollee Beneficiary Survey (web option screenshots)	Form and Instruction	Modified	Available
20. Public Comment Response_19July2016.docx	Supplementary Document	Uploaded 2016-07-20	Available
16. EmergencyJustification_16July2016.docx	Supplementary Document	Uploaded 2016-07-20	Repair queued
CMS-10615 Emergency Justification (signed by CMS Administrator).pdf	Supplementary Document	Uploaded 2016-05-04	Available
81 FR 26798 (30).pdf	Supplementary Document	Uploaded 2016-05-04	Available
22. SupportingMaterials_OMBPackage_HIP2-0_FocusGroups.pdf	Supplementary Document	Uploaded 2016-05-04	Available
13. SupportingStatement_PartA_19July2016.docx	Supporting Statement A	Uploaded 2016-07-20	Available
14. SupportingStatement_PartB_19July2016.docx	Supporting Statement B	Uploaded 2016-07-20	Available
28. Public Comment_NHeLP_Response_27Apr2016_508.pdf	Supplementary Document	Uploaded 2016-05-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221371	Informational Interviews	Form and Instruction	New	2016 Interview Guide
221370	Focus Groups	Form and Instruction	New	Participant Informed Consent
221370	Focus Groups	Other-Telephone Recruitment Script	New
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper)
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 Beneficiary Survey: Enrollees (paper)
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots)
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots)
220696	Beneficiaries Survey	Form and Instruction	Modified	HIP 2.0 Enrollee Beneficiary Survey (web option screenshots)
220696	Beneficiaries Survey	Other-Survey Cover Letter II	Modified

ICR Details

OMB Control No: 0938-1300	ICR Reference No: 201605-0938-003
Status: Historical Active	Previous ICR Reference No: 201603-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey, Focus Groups, and Informational Interviews (CMS-10615)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 06/10/2016
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/21/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/04/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	6 Months From Approved	09/30/2016
Responses	5,240	0	36
Time Burden (Hours)	1,443	0	36
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: This is a continuation of the Emergency ICR which was approved by OMB on March 21, 2016. This initial ICR was for testing/developing the survey instrument while this proposed iteration is for implementing the survey effort, focus groups, and informational interviews. The approved Emergency Justification is attached to this package.

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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
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 26798	05/04/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiaries Survey	CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615	HIP 2.0 Enrollee Beneficiary Survey (web option screenshots) ,   HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots) ,   HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots) ,   HIP 2.0 Beneficiary Survey: Enrollees (paper) ,   HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper) ,   HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)
Focus Groups	CMS-10615	Participant Informed Consent
Informational Interviews	CMS-10615	2016 Interview Guide

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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	5,240	36	0	5,204	0	0
Annual Time Burden (Hours)	1,443	36	0	1,407	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 survey instrument testing effort resulted in 15 participants with a total burden of 15 hours. For this proposed implementation information collection request, the target number of survey respondents is 5,182 with a total of 1,296 hours assuming a 15-minute average survey administration time. The additional burden of the focus groups (120 burden hours) and the informational interviews (27 burden hours) combined with the survey burden totals 1,443 hours per year.

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Annual Cost to Federal Government: $433,549

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: 05/04/2016

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