Information Collection

Beneficiaries Survey

IC 220696 under ICR 201605-0938-003 · OMB 0938-1300.

⚠️ Notice: This information collection may be referencing outdated material.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

2018-07-05 - No material or nonsubstantive change to a currently approved collection
2018-04-06 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10615 HIP 2.0 Enrollee Beneficiary Survey (web option screenshots) Beneficiaries Survey	Form and Instruction
Form CMS-10615 HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots) Beneficiaries Survey	Form and Instruction
Form CMS-10615 HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots) Beneficiaries Survey	Form and Instruction
Form CMS-10615 HIP 2.0 Beneficiary Survey: Enrollees (paper) Beneficiaries Survey	Form and Instruction
Form CMS-10615 HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper) Beneficiaries Survey	Form and Instruction
Form CMS-10615 HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper) 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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.