Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Modified	Available
CMS-P-0015A.CAPI screenshots-FINAL 9-21-18.docx	Supplementary Document	Uploaded 2018-09-24	Available
CMS-P-0015A.MCBS_Community Brochure_English_JuneUpdate.pdf	Supplementary Document	Uploaded 2018-09-24	Available
ResidentConsentForm508.docx	Supplementary Document	Uploaded 2018-05-23	Available
NextofKinConsentForm508.docx	Supplementary Document	Uploaded 2018-05-23	Available
HIPAALetter508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
FacilityAdvanceLetter508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
MCBS Facility Brochure_English.pdf	Supplementary Document	Uploaded 2018-05-23	Available
CMSThankYouLetterEng508.docx	Supplementary Document	Uploaded 2018-05-23	Available
RefusalLetterContinuingREng508.docx	Supplementary Document	Uploaded 2018-05-23	Available
210718AtTheDoorEnglish508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
CommunityAuthorityLetter508.docx	Supplementary Document	Uploaded 2018-05-23	Available
201718CalendarEnglish508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
CommunityAdvanceLetter508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
MCBS IAQ Brochure_English.pdf	Supplementary Document	Uploaded 2018-05-23	Available
MCBS Community Brochure_English.pdf	Supplementary Document	Uploaded 2018-05-23	Available
2018RespondentNewsletterEnglish508.pdf	Supplementary Document	Uploaded 2018-05-23	Available
CMS-P-0015A (0938-0568). Supporting Statement Part A (2018) - FINAL 9-21-18.docx	Supporting Statement A	Uploaded 2018-09-24	Available
CMS-P-0015A (0938-0568). Supporting Statement Part B (2018) - FINAL 9-21-18.docx	Supporting Statement B	Uploaded 2018-09-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 201805-0938-015
Status: Historical Active	Previous ICR Reference No: 201711-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)
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: 09/25/2018
	Date Received in OIRA: 05/23/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	06/30/2019
Responses	43,199	0	49,650
Time Burden (Hours)	44,165	0	60,103
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 723 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   PL: Pub.L. 111 - 148 3021 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:
	83 FR 11752	03/16/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 23916	05/23/2018
Did the Agency receive public comments on this ICR? No

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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 Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A	Comm2017R77KNQ ,   2019CommShowcards_ForOMB30Day ,   Comm2017R78IAQ ,   Comm2017R79DIQ ,   Comm2017R79END ,   Comm2017R79ENS ,   Comm2017R79ERQ ,   Comm2017R79HAQ ,   Comm2017R79HHQ ,   Comm2017R79HHS ,   Comm2017R79INQ ,   Comm2017R79IPQ ,   Comm2017R79IUQ ,   Comm2017R79MBQ ,   Comm2017R79OPQ ,   Comm2017R79PMQ ,   Comm2017R79PSQ ,   Comm2018R80ACQ ,   Comm2018R80USQ ,   Comm2018R81RXQ ,   Comm2018R82HFQ ,   Comm2018R82NAQ ,   Comm2018R82SCQ ,   Comm2019R83CPS ,   Comm2019R83DVH ,   Comm2019R83HIQ ,   Comm2019R83MPQ ,   Comm2019R83NSQ ,   Comm2019R83OMQ ,   Comm2019R83STQ ,   Comm2019R84CPQ ,   Comm2019R85PVQ ,   Attachment 4 Facility Screener ,   2019FacilityShowcards_ForOMB ,   Fac2017R79RH ,   Fac2017R79RHM ,   Fac2017R79US ,   Fac2019R85BQ ,   Fac2019R85BQM ,   Fac2019R85EX ,   Fac2019R85FQ ,   Fac2019R85FQM ,   Fac2019R85HS ,   Fac2019R85IN ,   OMB Facility Specs 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	43,199	49,650	0	-6,451	0	0
Annual Time Burden (Hours)	44,165	60,103	0	-15,938	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The annual respondent burden for the MCBS will be reduced due to the elimination of the 12th interview for respondents completing their exit interview.

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Annual Cost to Federal Government: $23,783,636

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

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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: 05/23/2018

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