Consumer Assessment of Healthcare Providers and Systems (CAHPS®)Home and Community Based Services (HCBS) Survey Database

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 Data Files Submission	Form and Instruction	New	Repair queued
Form 3 Data Use Agreement	Form and Instruction	New	Repair queued
Form 2 Program Information Form	Form and Instruction	New	Repair queued
Form 1 Attachment A: Adult HCBS Registration Form	Form	New	Repair queued
HCBS Database-OMB Statement B-FINAL_11.26.docx	Supporting Statement B	Uploaded 2019-07-23	Available
HCBS Database_OMB Statement A.FINAL_3.29.docx	Supporting Statement A	Uploaded 2019-07-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237061	Data Files Submission	Form and Instruction	New	Data Files Submission
237059	Data Use Agreement	Form and Instruction	New	Data Use Agreement
237058	Program Information Form	Form and Instruction	New	Program Information Form
236877	Adult HCBS Registration Form	Form	New	Attachment A: Adult HCBS Registration Form

ICR Details

OMB Control No: 0935-0245	ICR Reference No: 201907-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Consumer Assessment of Healthcare Providers and Systems (CAHPS®)Home and Community Based Services (HCBS) Survey Database
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 without change	Conclusion Date: 10/24/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/25/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved
Responses	205	0	0
Time Burden (Hours)	63	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The CAHPS Home and Community-Based Services Survey is the first cross-disability survey of home and community-based service beneficiaries’ experience receiving long-term services and supports. It is designed to facilitate comparisons across state Medicaid HCBS programs throughout the country that target adults with disabilities, e.g., including frail elderly, individuals with physical disabilities, persons with developmental or intellectual disabilities, those with acquired brain injury and persons with severe mental illness. The HCBS CAHPS Survey was developed by the Centers for Medicare & Medicaid Services (CMS) for voluntary use by state Medicaid programs, including both fee-for-service HCBS programs as well as managed long-term services and supports (MLTSS) programs. States with adequate sample sizes may consider using survey metrics in value-based purchasing initiatives. The HCBS-CAHPS Database will serve as a primary source of data available to states, agency programs and researchers to help answer important questions related to beneficiary experiences. AHRQ, through its contractor, will collect and make available de-identified survey data, enabling HCBS programs to identify areas where quality can be improved. Rationale for the information collection. Aggregated HCBS Database results will be made publicly available on AHRQ’s CAHPS website. Technical assistance will be provided by AHRQ through its contractor, Westat at no charge to programs to facilitate the access and use of these materials for quality improvement and research. Technical assistance will also be provided to support HCBS-CAHPS data submission.

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Agency for Healthcare Research and Quality Act of 1999
  

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:
	84 FR 10085	03/19/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 32174	07/05/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Adult HCBS Registration Form	1	Attachment A: Adult HCBS Registration Form
Data Files Submission	4	Data Files Submission
Data Use Agreement	3	Data Use Agreement
Program Information Form	2	Program Information Form

---

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	205	0	0	205	0	0
Annual Time Burden (Hours)	63	0	0	63	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 first time ICR.

---

Annual Cost to Federal Government: $449,000

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

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.     Yes

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: 07/25/2019

---