Medicare Current Beneficiary Survey (MCBS)

Forms and Documents

Document Name	Status
Form CMS_P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A) Form and Instruction	Modified
Resident Consent Form (6-15-16).pdf Supplementary Document	2016-06-22
Next of Kin Consent Form (6-15-16).pdf Supplementary Document	2016-06-22
MCBS Faclity Brochure. (6-15-16).pdf Supplementary Document	2016-06-22
HIPAA Letter_English. (6-15-16).pdf Supplementary Document	2016-06-22
Facility Advance Letter (6-15-16).pdf Supplementary Document	2016-06-22
Thank You Letter (6-15-16).pdf Supplementary Document	2016-06-22
MCBS Community Brochure (6-15-16).pdf Supplementary Document	2016-06-22
IAQ Brochure (6-15-16).pdf Supplementary Document	2016-06-22
Community Authority Letter (6-15-16).pdf Supplementary Document	2016-06-22
Community Advance Letter_English (6-15-16).pdf Supplementary Document	2016-06-22
At the Door Sheet_English (6-15-16).pdf Supplementary Document	2016-06-22
2016-17 MCBS Calendar-Planner (6-15-16).pdf Supplementary Document	2016-06-22
2016 Winter Respondent Newsletter (6-15-16).pdf Supplementary Document	2016-06-22
Attachment 7 Resident Consent Form.pdf Supplementary Document	2016-05-06
Attachment 7 Next of Kin Consent Form.pdf Supplementary Document	2016-05-06
Attachment 7 MCBS Brochure_Facility_Eng.pdf Supplementary Document	2016-05-06
Attachment 7 HIPAA Letter_English.pdf Supplementary Document	2016-05-06
Attachment 7 CMS Advance Letter_Facility_English.pdf Supplementary Document	2016-05-06
MCBS Cognitive Testing LGBT Items 10 day letter_revised072815clean.docx Supplementary Document	2016-05-06
Attachment 3 MCBS Community Questionnaire Flow Diagrams_R76.pdf Supplementary Document	2016-05-06
Attachment 2 MCBS Respondent Newsletter 2016_Draft.pdf Supplementary Document	2016-05-06
Attachment 2 MCBS Brochure_Community_Eng.pdf Supplementary Document	2016-05-06
Attachment 2 IAQ Brochure_English.pdf Supplementary Document	2016-05-06
Attachment 2 Community Authority Letter.pdf Supplementary Document	2016-05-06
Attachment 2 CMS Thank You Letter_Community_English.docx Supplementary Document	2016-05-06
Attachment 2 CMS Advance Letter_Community_English.pdf Supplementary Document	2016-05-06
Attachment 2 At the Door Sheet_English.pdf Supplementary Document	2016-05-06
Attachment 2 2015-2016 MCBS Calendar_English.pdf Supplementary Document	2016-05-06
CMS-P-0015A (0938-0568) Supporting Statement B - 6-22-16 (clean).docx Supporting Statement B	2016-06-22
CMS-A-0015A (0938-0568) Supporting Statement A - 6-13-16 (clean).docx Supporting Statement A	2016-06-22

IC Document Collections

IC ID	Document Title	Status
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 201605-0938-004
Status: Historical Active	Previous ICR Reference No: 201601-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 20757
Title: Medicare Current Beneficiary Survey (MCBS)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/27/2016
	Date Received in OIRA: 05/09/2016
Terms of Clearance: Approved consistent with the understanding that changes to the MCBS questionnaire will continue to be submitted to OMB for approval, and CMS will update OMB on their ongoing plans for the modernization effort with each submission.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	07/31/2017
Responses	49,650	0	49,650
Time Burden (Hours)	60,103	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.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 723 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   PL: Pub.L. 111 - 148 3021 Name of Law: Affordable Care 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:
	81 FR 9201	02/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 26573	04/29/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	CMS-P-0015A, CMS_P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A	MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS ,   MCBS

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ICR Summary 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)	60,103	58,450	0	0	1,653	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: There has been a slight increase in the total annual burden estimate. Overall, the ICR has been revised to account for new questions in the survey.

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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: 05/09/2016

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