Beneficiaries Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1300 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10615 Beneficiaries Survey Form and Instruction
10. HIP 2.0 CoverLetter_English_16July2016.docx Other-Survey Cover Letter II
11. HIP 2.0 Prenotification Letter_16July2016.docx Other-Survey Prenotification Letter
12. Reminder Card_16July2016.docx Other-Survey Reminder II
CMS-10615 HIP 2.0 Enrollee Beneficiary Survey (web option screensh 4. Enrollee Web Survey v.2 0719 NoExpDate.docx Form and Instruction
CMS-10615 HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web 6. Disenrollee Web Survey v.2 0720 NoExpDate.docx Form and Instruction
CMS-10615 HIP 2.0 New Enrollee Beneficiary Survey (web option scre 2. THOR_HIPNEW_ENG_SVY_07.19_PROOF.pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: Enrollees (paper) 1. THOR_HIPENR_ENG_SVY_07.20_PROOF.pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (pap 3. THOR_HIPDIS_ENG_SVY_07.20_PROOF.pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper) 2. THOR_HIPNEW_ENG_SVY_07.19_PROOF.pdf Form and Instruction
18. HIP2.0_BeneficiarySurveyCrosswalk_16July2016.xlsx Survey Crosswalk II IC Document

Information Collection (IC) Details

IC Title:	Beneficiaries Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper)	3. THOR_HIPDIS_ENG_SVY_07.20_PROOF.pdf	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)	2. THOR_HIPNEW_ENG_SVY_07.19_PROOF.pdf	No		Paper Only
Other-Survey Prenotification Letter II			11. HIP 2.0 Prenotification Letter_16July2016.docx	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots)	2. THOR_HIPNEW_ENG_SVY_07.19_PROOF.pdf	Yes	Yes	Fillable Fileable
Other-Survey Reminder II			12. Reminder Card_16July2016.docx	No		Paper Only
Other-Survey Cover Letter II			10. HIP 2.0 CoverLetter_English_16July2016.docx	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: Enrollees (paper)	1. THOR_HIPENR_ENG_SVY_07.20_PROOF.pdf	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Enrollee Beneficiary Survey (web option screenshots)	4. Enrollee Web Survey v.2 0719 NoExpDate.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10615	HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots)	6. Disenrollee Web Survey v.2 0720 NoExpDate.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,182	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,182	5,146	36
Annual IC Time Burden (Hours)	1,296	1,260	36
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Crosswalk II	18. HIP2.0_BeneficiarySurveyCrosswalk_16July2016.xlsx	07/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.