In-Center Hemodialysis CAHPS Survey (CMS-10105)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10105 In-Center Hemodialysis CAHPS Survey: Mode	Form	Removed	Available
Attachment_F_Response_to_Comments_60_FRN_CMS-10105_020817_AfterOMBCALL_C....docx	Supplementary Document	Uploaded 2017-02-08	Available
CMS-10105 - Supporting_Statement_A [rev 09-27-2016 by OSORA PRA].docx	Supporting Statement A	Uploaded 2016-09-28	Available
Attachment_F_Response_to_Comments_60_FRN_CMS-10105_090716.docx	Supplementary Document	Uploaded 2016-09-27	Available
CMS-10105_Supporting_Statement_part_B_051816.docx	Supporting Statement B	Uploaded 2016-09-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8773	In-Center Hemodialysis CAHPS Survey: Mode	Form	Removed
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Other-Pre-Notification Letter (English and Spanish)	Modified

ICR Details

OMB Control No: 0938-0926	ICR Reference No: 201609-0938-014
Status: Historical Active	Previous ICR Reference No: 201307-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: In-Center Hemodialysis CAHPS Survey (CMS-10105)
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: 02/09/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/28/2016
Terms of Clearance: Approved consistent with the understanding that no later than 2/1/2018, CMS will brief OMB on progress on the following activities: 1) Focus group testing of the current survey instrument to assess potential for further streamlining, 2) re-assessment of the survey literacy level, 3) examination of the accuracy of multi-lingual translations of the instrument, 4) exploration of web-based administration of the survey.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	218,656	0	325,000
Time Burden (Hours)	59,037	0	87,750
Cost Burden (Dollars)	0	0	0

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Abstract: Administration of In-center Hemodialysis CAHPS(ICH CAHPS) survey by more than 5,700 Medicare-certified ESRD facilities is required as part of the value-based purchasing program for payments under the Medicare program, as described in the 2016 proposed and final ESRD Prospective System Payment Update Rules published in the Federal Register on July 1, 2015, and November 6, 2015, respectively. Value-based purchasing promotes CMS’ goals: better healthcare for individuals; better care for populations and communities; and, lower costs through improvement. Beginning in CY2014, ICH facilities are required to contract with a CMS-approved survey vendor to implement the survey; the CMS-approved vendor shall follow a set of standardized survey administration procedures developed for the national implementation. Survey results from the national implementation will be publicly reported on the DFC website on www.medicare.gov.

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Authorizing Statute(s): US Code: 42 USC 1881(h) 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
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 38187	06/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 65653	09/23/2016
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
In-Center Hemodialysis CAHPS Survey: Mode	CMS-10105, CMS-10105	Attachment C - Final ICH CAHPS Survey (English and Spanish) ,   Attachment E - Telephone Script (English and Spanish)
In-Center Hemodialysis CAHPS Survey: National Implementation	CMS-10105	Medicare In-Center Hemodialysis Survey (English and Spanish)

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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	218,656	325,000	0	-5,000	-101,344	0
Annual Time Burden (Hours)	59,037	87,750	0	-1,350	-27,363	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The implementation hour burden has been adjusted from 86,400 as approved in the currently approved projection to 59,037 (-27,363) due to a lower response rate than originally planned. The mode experiment is complete, reducing the time estimate by an additional -1,350 hours.

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Annual Cost to Federal Government: $1,764,387

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: 09/28/2016

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