Medicare Beneficiary Experiences with Care Survey (MBECS) System(CMS-10701)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10701 Medicare Beneficiary Experiences with Care Survey (MBECS) System	Form and Instruction	New	Repair queued
MBECS Supporting Statement Part B_04182019.pdf	Supporting Statement B	Uploaded 2019-12-27	Repair queued
MBECS Supporting Statement Part A_05212019.docx	Supporting Statement A	Uploaded 2019-12-27	Repair queued
SNPA Comment on MBECS survey July 17, 2019.pdf	Supplementary Document	Uploaded 2019-12-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
239103	Medicare Beneficiary Experiences with Care Survey (MBECS) System	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201912-0938-022
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: OMH
Title: Medicare Beneficiary Experiences with Care Survey (MBECS) System(CMS-10701)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/02/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	10,000	0
Time Burden (Hours)	3,333	0
Cost Burden (Dollars)	0	0

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Abstract: This study is being conducted by CMS OMH through its contractor, NORC at the University of Chicago, pursuant to CMS’s program authority under Section 3101 of the Public Health Service Act (PHSA) to collect, maintain, and issue defined reports on demographic data as deemed appropriate regarding health disparities.The population-specific questionnaire module will collect information about issues most relevant for particular minority groups; population-specific modules will be described in individual information collection requests. These data will be compared to benchmarks from the relevant CAHPS source surveys when available.

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Authorizing Statute(s): None

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 25059	05/30/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 71427	12/27/2019
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 Beneficiary Experiences with Care Survey (MBECS) System	CMS-10701	(MBECS)Core Questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	10,000	0	0	10,000	0	0
Annual Time Burden (Hours)	3,333	0	0	3,333	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: New Collection estimates only presented here

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Annual Cost to Federal Government: $1,771,217

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.     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? No

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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: 01/02/2020

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