Beneficiaries Survey

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

OMB: 0938-1300

IC ID: 220696

Information Collection (IC) Details

View Information Collection (IC)

Beneficiaries Survey
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10615 HIP 2.0 Enrollee Beneficiary Survey (web option screenshots) 4.Enrollee_Web_Survey_v.2_0719_ExpDate_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10615 HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots) 5.New Enrollee Web Survey v.2 0719 ExpDate_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10615 HIP 2.0 Beneficiary Survey: Enrollees (paper) 1. THOR_HIPENR_ENG_SVY_07.20_PROOF (rev 09-28-2016).pdf No   Paper Only
Other-Survey Cover Letter II 10. HIP 2.0 CoverLetter_English_16July2016 (rev 09-28-2016).docx No   Paper Only
Other-Survey Reminder II 12. Reminder Card_16July2016 (rev 09-28-2016).docx No   Paper Only
Form and Instruction CMS-10615 HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper) 3. THOR_HIPDIS_ENG_SVY_07.20_PROOF (rev 09-28-2016).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 (rev 09-28-2016).pdf No   Paper Only
Other-Survey Prenotification Letter II 11. HIP 2.0 Prenotification Letter_16July2016 (rev 09-28-2016).docx No   Paper Only
Form and Instruction CMS-10615 HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots) 6.DisenrolleeWebSurvey_v.2_0719ExpDate_508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

5,182 0
   
Individuals or Households
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,182 0 0 0 0 5,182
Annual IC Time Burden (Hours) 1,296 0 0 0 0 1,296
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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