(CMS-10393) Beneficiary and Family Centered Data Collection

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey	Form and Instruction	Modified	Available
CMS-10393 11th_SOW_Supporting Statement_Part_B_ 02 15 2018.docx	Supporting Statement B	Uploaded 2018-02-15	Available
CMS-10393 11th_SOW_Supporting Statement_Part_A_ 02 15 2018.docx	Supporting Statement A	Uploaded 2018-02-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201543	Medicare Beneficiary and Family-Centered Satisfaction Survey	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1177	ICR Reference No: 201707-0938-002
Status: Active	Previous ICR Reference No: 201509-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: 19423
Title: (CMS-10393) Beneficiary and Family Centered Data Collection
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: 02/20/2018
	Date Received in OIRA: 07/06/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2021	36 Months From Approved	09/30/2019
Responses	24,970	0	16,010
Time Burden (Hours)	2,899	0	4,003
Cost Burden (Dollars)	31,213	0	20,013

---

Abstract: To ensure the QIOs are effectively meeting their goals, CMS has historically collected patient experience information through a survey of beneficiaries who have interacted directly with a QIO representative. In this way, CMS assesses the degree to which the QIOs are achieving the above program requirements; provides feedback to the QIOs to support them in improving the services they deliver to Medicare beneficiaries; and measures the degree to which the QIOs are meeting their contractual obligations as laid out in their SOW. CMS must continue to collect reliable and rich data on the experiences of Medicare beneficiaries. The nature of the data collected must also evolve as QIO contract changes so that CMS is adequately capturing how, when, and why QIOs are interacting with beneficiaries and beneficiary reports on their related experiences.

---

Authorizing Statute(s): US Code: 42 USC 1320c Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 17997	04/14/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 29864	06/30/2017
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393, CMS-10393, CMS-10393	Attachment A: Beneficiary Experience Survey ,   Attachment B: Direct Follow-up ,   Attachment C: General Feedback Web Survey

---

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	24,970	16,010	0	8,960	0	0
Annual Time Burden (Hours)	2,899	4,003	0	-1,104	0	0
Annual Cost Burden (Dollars)	31,213	20,013	0	11,200	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 revised data collection approach will increase the burden hours from 1,601 to 2,899. The burden from the previous package was not revised in ROCIS when the Supporting Statement was updated due to a passback so ROCIS has 4,003 hours for the previous submittal but it should be 1,601 hours.

---

Annual Cost to Federal Government: $1,588,862

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? No

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

---

Common Form ICR:  No

---

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: 07/06/2017

---