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 Health Status	Form	Modified	Repair queued
Form CMS-P-0015A Health_Status	Form	Modified	Repair queued
Form CMS-P-0015A Health_Insurance	Form	Modified	Repair queued
Form CMS-P-0015A Questionaire	Form	Modified	Available
Form CMS-P-0015A Questionaire Missing Data	Form	Modified	Available
Form CMS-P-0015A Expenditures	Form	Modified	Available
Form CMS-P-0015A Background_Questionnaire MIssing Data	Form	Modified	Available
Form CMS-P-0015A Background_Questionnaire	Form	Modified	Available
Form CMS-P-0015A Use of Health Services	Form	Modified	Repair queued
Form CMS-P-0015A Residence History	Form	Modified	Available
Form CMS-P-0015A Residence History Missing Data	Form	Modified	Available
Form CMS-P-0015A Facility Showcards	Form	Modified	Available
Form CMS-P-0015A Showcards and Reference Cards	Form	Modified	Available
Form CMS-P-0015A Usual Source of Care	Form	Modified	Available
Form CMS-P-0015A Preventive Care	Form	Modified	Available
Form CMS-P-0015A Beneficiary Knowledge	Form	Modified	Available
Form CMS-P-0015A Statement Cost Series	Form	Modified	Repair queued
Form CMS-P-0015A Satisfaction Care	Form	Modified	Available
Form CMS-P-0015A Prescribed Medicine Utilization	Form	Modified	Available
Form CMS-P-0015A Outpatient Utilization	Form	Modified	Available
Form CMS-P-0015A Other Medical Expense	Form	Modified	Available
Form CMS-P-0015A No Statement Cost	Form	Modified	Available
Form CMS-P-0015A Nicotine Alcohol	Form	Modified	Repair queued
Form CMS-P-0015A Medical Provider Utilzation	Form	Modified	Available
Form CMS-P-0015A Introduction	Form	Modified	Available
Form CMS-P-0015A Institutional Utilization	Form	Modified	Available
Form CMS-P-0015A Inpatient Utilization	Form	Modified	Available
Form CMS-P-0015A Income_and_ Assets	Form	Modified	Available
Form CMS-P-0015A Housing_Characteristics	Form	Modified	Available
Form CMS-P-0015A Home Health	Form	Modified	Available
Form CMS-P-0015A Health Insurance	Form	Modified	Available
Form CMS-P-0015A Emergency Utilization	Form	Modified	Repair queued
Form CMS-P-0015A Drug Coverage	Form	Modified	Available
Form CMS-P-0015A Dental, Vision, and Hearing Care Utilization	Form	Modified	Available
Form CMS-P-0015A Chronic Pain	Form	Modified	Available
Form CMS-P-0015A Access to Care	Form	Modified	Repair queued
Form CMS-P-0015A Post Statement Cost	Form	Modified	Available
Form CMS-P-0015A Mobility of Beneficiaries	Form	Modified	Repair queued
Form CMS-P-0015A nterviewer Remarks	Form	Modified	Repair queued
Form CMS-P-0015A Home Health Summary	Form	Modified	Available
Form CMS-P-0015A Enumeration Summary	Form	Modified	Available
Form CMS-P-0015A End Questionaire	Form	Modified	Available
Form CMS-P-0015A Demographic Income	Form	Modified	Repair queued
Form CMS-P-0015A Cost Payment Summary	Form	Modified	Available
Form CMS-P-0015A Facility Screener	Form	Modified	Available
CMS-P-0015A (0935-0568) Supporting Statement A - Passback2 responses Cle....docx	Supporting Statement A	Uploaded 2019-12-03	Available
CMS P 0015A MCBS nonsubstantive change request R88 Passback Clean.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-01-10	Available
Summary of Questionnaire Changes_OMB Passback.pdf	Supplementary Document	Uploaded 2019-08-06	Available
CMS-P-0015A (0935-0568) Supporting Statement B - Passback2 responses Cle....docx	Supplementary Document	Uploaded 2019-08-06	Available
CMS-P-0015A (0935-0568) Supporting Statement A - Passback2 responses Cle....docx	Supplementary Document	Uploaded 2019-08-06	Available
Next of Kin Consent Form.pdf	Supplementary Document	Uploaded 2019-04-16	Available
Resident Consent Form.pdf	Supplementary Document	Uploaded 2019-04-16	Available
MCBS Facility Brochure_Eng.pdf	Supplementary Document	Uploaded 2019-04-16	Available
HIPAA Letter.doc	Supplementary Document	Uploaded 2019-04-16	Repair queued
Facility Advance Letter.doc	Supplementary Document	Uploaded 2019-04-16	Available
Thank You Letter_Comm_Eng.doc	Supplementary Document	Uploaded 2019-04-16	Available
Refusal Letter_Com_Continuing Rs_Eng_FM800.doc	Supplementary Document	Uploaded 2019-04-16	Available
MCBS IAQ Brochure_Eng.pdf	Supplementary Document	Uploaded 2019-04-16	Available
MCBS Community Brochure_Eng.pdf	Supplementary Document	Uploaded 2019-04-16	Repair queued
Community Authority Letter.doc	Supplementary Document	Uploaded 2019-04-16	Available
Community Advance Letter_Comm_Eng.doc	Supplementary Document	Uploaded 2019-04-16	Available
AtTheDoorEnglish.pdf	Supplementary Document	Uploaded 2019-04-16	Available
2019-2020 MCBS Calendar ENG.pdf	Supplementary Document	Uploaded 2019-04-16	Available
2019_Winter Respondent Newsletter- Eng.pdf	Supplementary Document	Uploaded 2019-04-16	Available
CMS-P-0015A (0935-0568) Supporting Statement B - Passback2 responses Cle....docx	Supporting Statement B	Uploaded 2019-08-06	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	Modified	Health Status
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health_Status
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health_Insurance
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Questionaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Questionaire Missing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Expenditures
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Background_Questionnaire MIssing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Background_Questionnaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Use of Health Services
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Residence History
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Residence History Missing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Facility Showcards
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Showcards and Reference Cards
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Usual Source of Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Preventive Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Beneficiary Knowledge
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Statement Cost Series
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Satisfaction Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Prescribed Medicine Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Outpatient Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Other Medical Expense
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	No Statement Cost
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Nicotine Alcohol
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Medical Provider Utilzation
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Introduction
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Institutional Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Inpatient Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Income_and_ Assets
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Housing_Characteristics
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Home Health
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health Insurance
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Emergency Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Drug Coverage
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Dental, Vision, and Hearing Care Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Chronic Pain
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Access to Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Post Statement Cost
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Mobility of Beneficiaries
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	nterviewer Remarks
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Home Health Summary
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Enumeration Summary
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	End Questionaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Demographic Income
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Cost Payment Summary
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Facility Screener

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 201912-0938-002
Status: Historical Active	Previous ICR Reference No: 201904-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)
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 with change	Conclusion Date: 01/13/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/03/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2022	08/31/2022	08/31/2022
Responses	35,998	0	35,998
Time Burden (Hours)	42,610	0	42,610
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:
	84 FR 731	01/31/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 15617	04/16/2019
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	Cost Payment Summary ,   Demographic Income ,   End Questionaire ,   Enumeration Summary ,   Home Health Summary ,   nterviewer Remarks ,   Mobility of Beneficiaries ,   Post Statement Cost ,   Access to Care ,   Chronic Pain ,   Dental, Vision, and Hearing Care Utilization ,   Drug Coverage ,   Emergency Utilization ,   Health Insurance ,   Home Health ,   Housing_Characteristics ,   Income_and_ Assets ,   Inpatient Utilization ,   Institutional Utilization ,   Introduction ,   Medical Provider Utilzation ,   Nicotine Alcohol ,   No Statement Cost ,   Other Medical Expense ,   Outpatient Utilization ,   Prescribed Medicine Utilization ,   Satisfaction Care ,   Statement Cost Series ,   Beneficiary Knowledge ,   Preventive Care ,   Usual Source of Care ,   Showcards and Reference Cards ,   Facility Showcards ,   Facility Screener ,   Residence History Missing Data ,   Residence History ,   Use of Health Services ,   Background_Questionnaire ,   Background_Questionnaire MIssing Data ,   Expenditures ,   Questionaire Missing Data ,   Questionaire ,   Health_Insurance ,   Health_Status ,   Health Status

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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	35,998	35,998	0	0	0	0
Annual Time Burden (Hours)	42,610	42,610	0	0	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $23,347,008

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: 12/03/2019

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