Montana Health and Economic Livelihood Partnership (HELP) Federal Evaluation (CMS-10635)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10625 Interview Guide	Form and Instruction	New	Available
Form CMS-10625 Core Focus Group Moderator’s Guide	Form and Instruction	New	Available
Form CMS-10635 Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots)	Form	New	Repair queued
Form CMS-10635 Beneficiary Survey: Disenrollees (Spanish, paper)	Form	New	Available
Form CMS-10635 Beneficiary Survey: Enrollees (Spanish, paper)	Form	New	Available
Form CMS-10635 Beneficiary Survey: Disenrollees (paper)	Form	New	Available
Form CMS-10635 Beneficiary Survey: Enrollees (paper)	Form	New	Available
Form CMS-10635 Disenrollee and Lockout Beneficiary Survey (Screen Shots)	Form	New	Available
Form CMS-10635 Enrollee Beneficiary Survey (Screen Shots)	Form	New	Available
CMS-10635 - Supporting Statement A (OMB Passback 1)_rev_clean.docx	Supporting Statement A	Uploaded 2017-06-23	Available
CMS-10635 - Supporting Statement B (OMB Passback 1)_rev_clean.docx	Supporting Statement B	Uploaded 2017-06-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226871	Informational Interviews	Form and Instruction	New	Interview Guide
226870	Beneficiary Focus Groups	Form and Instruction	New	Core Focus Group Moderator’s Guide
226870	Beneficiary Focus Groups	Other-Telephone Recruitment Script	New
226869	Beneficiary Surveys	Form	New	Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots)
226869	Beneficiary Surveys	Form	New	Beneficiary Survey: Disenrollees (Spanish, paper)
226869	Beneficiary Surveys	Form	New	Beneficiary Survey: Enrollees (Spanish, paper)
226869	Beneficiary Surveys	Form	New	Beneficiary Survey: Disenrollees (paper)
226869	Beneficiary Surveys	Form	New	Beneficiary Survey: Enrollees (paper)
226869	Beneficiary Surveys	Form	New	Disenrollee and Lockout Beneficiary Survey (Screen Shots)
226869	Beneficiary Surveys	Form	New	Enrollee Beneficiary Survey (Screen Shots)

ICR Details

OMB Control No: 0938-1332	ICR Reference No: 201705-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Montana Health and Economic Livelihood Partnership (HELP) Federal Evaluation (CMS-10635)
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 with change	Conclusion Date: 06/23/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/16/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	1,485	0	0
Time Burden (Hours)	568	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request is for conducting a customer satisfaction survey, focus groups, and informational interviews as part of site visits to Billings, Helena, Blackfeet Indian Reservation, and Havre in Montana, relating to the Montana Health and Economic Livelihood Partnership (HELP) Program Demonstration. Respondents will include beneficiaries enrolled and disenrolled in the HELP Medicaid Demonstration as well as stakeholders and consumer advocates. The data collection effort is part of a larger federal assessment of the HELP Demonstration that will inform the continued policy decision making regarding the HELP Demonstration (Section 1115 Demonstration) as well as other similar Medicaid expansion policies.

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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 72806	10/21/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 16844	04/06/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiary Focus Groups	CMS-10625	Core Focus Group Moderator’s Guide
Beneficiary Surveys	CMS-10635, CMS-10635, CMS-10635, CMS-10635, CMS-10635, CMS-10635, CMS-10635	Enrollee Beneficiary Survey (Screen Shots) ,   Disenrollee and Lockout Beneficiary Survey (Screen Shots) ,   Beneficiary Survey: Enrollees (paper) ,   Beneficiary Survey: Disenrollees (paper) ,   Beneficiary Survey: Enrollees (Spanish, paper) ,   Beneficiary Survey: Disenrollees (Spanish, paper) ,   Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots)
Informational Interviews	CMS-10625	Interview Guide

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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	1,485	0	0	1,485	0	0
Annual Time Burden (Hours)	568	0	0	568	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: $499,541

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

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: 05/16/2017

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