Evaluating Coverage to Care (C2C) (CMS-10632)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10632 Case Study: Explanation of Consent, Short Survey, and Focus Group Facilitation Guide	Form and Instruction	New	Repair queued
Form CMS-10632 Appendix C - Case Study Explanation of Consent and Semi-Structured Interview	Form and Instruction	New	Available
Form CMS-10632 Consumer Survey and Informed Consent	Form and Instruction	New	Available
Form CMS-10632 Appendix A - Organization Survey: Informed Consent and Survey	Form and Instruction	New	Available
CMS-10632.Appendix G - Recruitment Scripts for Online Surveys, Focus Groups, and Interviews.docx	Supplementary Document	Uploaded 2017-04-12	Available
CMS-10632.Appendix H - Support Letter from CMS OMH.docx	Supplementary Document	Uploaded 2017-04-12	Repair queued
CMS-10632. Appendix F - Responses to public comments.docx	Supplementary Document	Uploaded 2017-04-12	Available
CMS-10632.Appendix E - Case Study Additional Study Components of Relevance to the C2C Evaluation that do not Require OMB Review.docx	Supplementary Document	Uploaded 2017-04-12	Available
CMS-10632.Supporting Statement Part B.docx	Supporting Statement B	Uploaded 2017-04-12	Available
CMS-10632.Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2017-04-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226371	Case Study: Focus Group	Form and Instruction	New	Case Study: Explanation of Consent, Short Survey, and Focus Group Facilitation Guide
226370	Case Study: Semi-structured Interviews	Form and Instruction	New	Appendix C - Case Study Explanation of Consent and Semi-Structured Interview
226369	Consumer Survey	Form and Instruction	New	Consumer Survey and Informed Consent
226367	Organizational Survey	Form and Instruction	New	Appendix A - Organization Survey: Informed Consent and Survey

ICR Details

OMB Control No: 0938-1342	ICR Reference No: 201704-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: OMH
Title: Evaluating Coverage to Care (C2C) (CMS-10632)
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: 09/18/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/12/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved
Responses	3,460	0	0
Time Burden (Hours)	1,176	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The proposed evaluation is intended to achieve two separate but related goals. First, it will provide information that will support CMS OMH to maximize the impact of C2C at the local, state, and national levels. The evaluation will support selecting the best dissemination activities to maximize the spread of C2C, developing new messaging on preventive visits and primary care, and creating additional products to fill critical gaps. Second, findings from the evaluation will help CMS to assess whether and how C2C improves consumer health literacy and care utilization.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 . 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 76358	11/02/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 14516	03/21/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Case Study: Focus Group	CMS-10632	Case Study: Explanation of Consent, Short Survey, and Focus Group Facilitation Guide
Case Study: Semi-structured Interviews	CMS-10632	Appendix C - Case Study Explanation of Consent and Semi-Structured Interview
Consumer Survey	CMS-10632	Consumer Survey and Informed Consent
Organizational Survey	CMS-10632	Appendix A - Organization Survey: Informed Consent and Survey

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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	3,460	0	0	3,460	0	0
Annual Time Burden (Hours)	1,176	0	0	1,176	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 information collection request.

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Annual Cost to Federal Government: $308,505

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 04/12/2017

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