Healthy Indiana Program (HIP) 2.0 Beneficiary Focus Groups (CMS-10615)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10615 Informational Interviews	Form and Instruction	Unchanged	Repair queued
Form CMS-10615 Beneficiaries Survey	Form and Instruction	Removed	Available
14. SupportingStatement_PartB_19July2016.docx	Supporting Statement B	Uploaded 2018-04-06	Available
17 Extension - CMS-10615 - Supporting Statement A [rev 09-28-2016 by OSORA PRA].docx	Supporting Statement A	Uploaded 2018-04-06	Repair queued
Justification for Nonsubstantive Change_5May2017_March2018_revised_clean.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-03-30	Available
SupportingMaterials_HIP 2.0FG_03.29.2018.CLEAN.docx	Supplementary Document	Uploaded 2018-03-30	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
221371	Informational Interviews	Form and Instruction	Unchanged
221370	Focus Groups	Other-Telephone Recruitment Script	Modified
220696	Beneficiaries Survey	Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1300	ICR Reference No: 201803-0938-011
Status: Historical Active	Previous ICR Reference No: 201609-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Healthy Indiana Program (HIP) 2.0 Beneficiary Focus Groups (CMS-10615)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/06/2018
	Date Received in OIRA: 04/06/2018
Terms of Clearance: We appreciate CMS' agreement to revise the supporting statements to reflect changes to the package over the last year.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	11/30/2019	11/30/2019
Responses	98	0	5,240
Time Burden (Hours)	267	0	1,443
Cost Burden (Dollars)	0	0	0

---

Abstract: Information will be used by CMS to adequately inform CMS decision making regarding Section 1115 Waivers. CMS and other stakeholders also will use the information as a point of comparison to states implementing similar demonstrations. Other states contemplating waivers may find the information helpful for their own decision-making processes.

---

Authorizing Statute(s): US Code: 42 USC 1315 Name of Law: Social Security Act
  

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:
	81 FR 47807	07/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 66031	09/26/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Informational Interviews	CMS-10615	2016 Interview Guide
Focus Groups	CMS-10615	Participant Informed Consent
Beneficiaries Survey	CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615, CMS-10615	HIP 2.0 Enrollee Beneficiary Survey (web option screenshots) ,   HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots) ,   HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots) ,   HIP 2.0 Beneficiary Survey: Enrollees (paper) ,   HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper) ,   HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)

---

ICR Summary 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	98	5,240	0	-5,142	0	0
Annual Time Burden (Hours)	267	1,443	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This iteration proposes a number of nonsubstantive changes, consisting of three adjustments. Adjustment #1 removes the beneficiary survey data collection activities. Adjustment #2 increases the number of focus groups in the State of Indiana. Adjustment #3 reflects changes to the focus group moderator guide. Adjustment #4 updates cost burden estimates based on more current wage rate data for Indiana. See Supporting Statement A under section 15 for details.

---

Annual Cost to Federal Government: $433,549

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]? 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

---

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: 04/06/2018

---