Medicare Health Outcomes Survey (HOS) (CMS-10203)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10203 Medicare Health Outcomes Survey (HOS)	Form	Modified	Available
Recent Publications from SEER-MHOS_06082018.docx	Supplementary Document	Uploaded 2018-07-18	Available
HOS Historical Crosswalk 06082018.xlsx	Supplementary Document	Uploaded 2018-07-18	Available
CMS-10203 - Supporting Statement A_rev 06082018 CLEAN.docx	Supporting Statement A	Uploaded 2018-07-18	Available
Attachment A_Crosswalk of Changes to HOS Proposed Questionnaire.pdf	Supplementary Document	Uploaded 2017-09-26	Available
CMS-10203 - Supporting Statement B_rev 06082018 CLEAN.docx	Supporting Statement B	Uploaded 2018-07-18	Available
PRA_Response_to_Public_Comments_CMS-2017-0048_08282017.docx	Supplementary Document	Uploaded 2017-09-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203728	Medicare Health Outcomes Survey (HOS)	Form	Modified

ICR Details

OMB Control No: 0938-0701	ICR Reference No: 201709-0938-006
Status: Active	Previous ICR Reference No: 201405-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Health Outcomes Survey (HOS) (CMS-10203)
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: 08/01/2018
	Date Received in OIRA: 09/27/2017
Terms of Clearance: We expect CMS will continue to evaluate the utility of patient reported outcome data and its use in Star Ratings. We look forward to future discussions during upcoming rulemaking.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	07/31/2018
Responses	1,485	0	1,737
Time Burden (Hours)	183,115	0	244,187
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services collects quality performance measures in order to hold the Medicare managed care industry accountable for the care being delivered, to enable quality improvement, and to provide quality information to Medicare beneficiaries in order to promote an informed choice. It is critical to CMS's mission that we collect and disseminate information that can be used to help beneficiaries choose among health plans, contribute to improved quality of care through identification of improvement opportunities, and assist CMS in carrying out its oversight and purchasing responsibilities.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   US Code: 42 USC 442, Subpart D Name of Law: null
  

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:
	82 FR 16843	04/06/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 41965	09/05/2017
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
Medicare Health Outcomes Survey (HOS)	CMS-10203, CMS-10203	Medicare Health Outcomes Survey (HOS 3.0) ,   Medicare Health Outcomes Survey-Modified (HOS-M)

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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	1,737	0	0	-252	0
Annual Time Burden (Hours)	183,115	244,187	0	0	-61,072	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: No

Burden Reduction Due to:

Short Statement: In this 2017 information collection request, Question 51 of the HOS has been revised to align with current USPSTF recommendations. There are no changes to the HOS-M. Burden adjustments (minus 61,072 hours) are the result of changes in the MA program, including changes in enrollment, the number of participating contracts, and contract size, rather than changes to the HOS survey protocol or instrument.

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Annual Cost to Federal Government: $2,415,000

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

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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: 09/27/2017

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