Evaluating a Pilot Mobile Health Program (CMS-10634)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10634 Information Interview	Form	New	Available
Form CMS-10634 Information Interview	Form	New	Available
Form CMS-10634 Information Interview	Form	New	Available
Form CMS-10634 Consent Form for Focus Groups for Evaluating a Pilot Mobile Health Program	Form	New	Available
Form CMS-10634 Focus Groups Call-In Script for Recruitment	Form	New	Available
Form CMS-10634 Focus group: Subscribers (Spanish version)	Form	New	Available
Form CMS-10634 Focus group: Subscribers	Form	New	Available
Form CMS-10634 Medicaid Postpartum Survey (Spanish)	Form	New	Available
Form CMS-10634 Medicaid Postpartum Survey	Form	New	Available
CMS-10634 - Supporting Statment B.DOCX	Supporting Statement B	Uploaded 2017-01-20	Available
CMS-10634 - Supporting Statement A [rev 01-20-2017 by OSORA PRA].docx	Supporting Statement A	Uploaded 2017-01-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
225199	Semi-structured interviews (Health care providers)	Form	New	Information Interview
225197	Semi-structured interviews (State and local outreach partners)	Form	New	Information Interview
225196	Semi-structured interviews (Representatives from CMCS, Voxiva and Zero to Three, and state Medicaid agencies)	Form	New	Information Interview
225195	Focus groups	Form	New	Consent Form for Focus Groups for Evaluating a Pilot Mobile Health Program
225195	Focus groups	Form	New	Focus Groups Call-In Script for Recruitment
225195	Focus groups	Form	New	Focus group: Subscribers (Spanish version)
225195	Focus groups	Form	New	Focus group: Subscribers
225195	Focus groups	Other-Text Messages to Recruit TEXT4BABY Subscribers for Focus G	New
225194	Telephone survey	Form	New	Medicaid Postpartum Survey (Spanish)
225194	Telephone survey	Form	New	Medicaid Postpartum Survey
225194	Telephone survey	Other-Selection Letter (English and Spanish)	New

ICR Details

OMB Control No: 0938-1339	ICR Reference No: 201701-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Evaluating a Pilot Mobile Health Program (CMS-10634)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/06/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/20/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved
Responses	1,679	0	0
Time Burden (Hours)	962	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Center for Medicaid & CHIP Services (CMCS), a division of the Centers for Medicare & Medicaid Services (CMS), is supporting a pilot mobile health (mHealth) program in California, Louisiana, Ohio, and Oklahoma. The three-year mHealth project is being conducted to complement existing CMCS measurement, data collection, and reporting activities to monitor, track, and assess state’s maternal and infant health efforts in Medicaid and CHIP populations. This project focuses on developing key measures of maternal and infant child health in the Medicaid population. This information will be used in monitoring performance of the participating states on the Maternity Core Set measures and in updating the Adult Core Set annually as required by Section 2701 of the Patient Protection and Affordable Care Act (ACA). Data for the evaluation will come from several primary and secondary data sources. The three primary data sources for which CMCS seeks Office of Management and Budget (OMB) clearance include: a postpartum telephone survey of Medicaid-enrolled pilot program participants and nonparticipants in the four pilot states, key informant interviews; and focus groups with Medicaid-enrolled pilot participants and nonparticipants.

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Authorizing Statute(s): None

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 71100	10/14/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 94379	12/23/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Focus groups	CMS-10634, CMS-10634, CMS-10634, CMS-10634	Focus group: Subscribers ,   Focus group: Subscribers (Spanish version) ,   Focus Groups Call-In Script for Recruitment ,   Consent Form for Focus Groups for Evaluating a Pilot Mobile Health Program
Semi-structured interviews (Health care providers)	CMS-10634	Information Interview
Semi-structured interviews (Representatives from CMCS, Voxiva and Zero to Three, and state Medicaid agencies)	CMS-10634	Information Interview
Semi-structured interviews (State and local outreach partners)	CMS-10634	Information Interview
Telephone survey	CMS-10634, CMS-10634	Medicaid Postpartum Survey ,   Medicaid Postpartum Survey (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	1,679	0	0	1,679	0	0
Annual Time Burden (Hours)	962	0	0	962	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $642,873

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: 01/20/2017

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