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	Modified	Repair queued
CMS-P-0015A_0935-0568_SSA.docx	Supporting Statement A	Uploaded 2020-12-07	Missing upstream
CMS-P-0015A_0935-0568_SSB.docx	Supporting Statement B	Uploaded 2020-12-07	Missing upstream
Thank You Letter English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Postcard_Phone.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Postcard_InPerson.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Letter_Phone_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Letter_NGACO.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Letter_In Person_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Reminder Advance Letter_Phone_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Non-response Letter_Continuing_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
IAQ Brochure English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Brochure_Phone_English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Brochure_InPerson_English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Authority Letter_NGACO.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Authority Letter.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Advance Letter_Phone_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Advance Letter_NGACO.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Advance Letter_InPerson_English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Community Advance Letter_COVID-19.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Facility Advance Letter_Phone.docx	Supplementary Document	Uploaded 2020-11-23	Available
Facility Advance Letter_InPerson.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Attachment7CAPIscreenshots.pdf	Supplementary Document	Uploaded 2020-08-19	Repair queued
Next of Kin Consent Form.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
Resident Consent Form.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
HIPAA Letter.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Refusal Letter_Com_Continuing Rs_Eng_FM800.doc	Supplementary Document	Uploaded 2019-04-16	Repair queued
At the Door Sheet English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
MCBS Calendar English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
MCBS Newsletter English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued

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

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 202011-0938-011
Status: Received in OIRA	Previous ICR Reference No: 202006-0938-012
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	Date Submitted to OIRA: 12/10/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2023
Responses	35,998	35,998
Time Burden (Hours)	54,426	44,363
Cost Burden (Dollars)	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:
	85 FR 57215	09/15/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 78853	12/07/2020
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, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, P-0015A, P-0015A	Health Status ,   Outpatient Utilization ,   Post Statement Cost ,   Health Insurance ,   Beneficiary Knowledge ,   Residence History Missing Data ,   Use of Health Services ,   Expenditures ,   Questionaire Missing Data ,   Questionaire ,   Health_Insurance ,   Nicotine Alcohol ,   Medical Provider Utilzation ,   Usual Source of Care ,   Residence History ,   Health_Status ,   Chronic Pain ,   Access to Care ,   Dental, Vision, and Hearing Care Utilization ,   Drug Coverage ,   Housing_Characteristics ,   Income_and_ Assets ,   Inpatient Utilization ,   Institutional Utilization ,   Other Medical Expense ,   Prescribed Medicine Utilization ,   Showcards and Reference Cards ,   Background_Questionnaire ,   interviewer Remarks ,   End Questionaire ,   Mobility of Beneficiaries ,   Emergency Utilization ,   Home Health ,   Introduction ,   No Statement Cost ,   Satisfaction Care ,   Statement Cost Series ,   Preventive Care ,   Facility Showcards ,   Facility Screener ,   Background_Questionnaire MIssing Data ,   Cost Payment Summary ,   Demographic Income ,   Enumeration Summary ,   Home Health Summary ,   Health_Status_and_Functioning ,   interviewer Remarks ,   Cognitive Measures ,   Physical_Measures ,   COVID-19 Questionnaire Specifications ,   MCBS COVID-19 Winter 2021 Facility Supplement

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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	35,998	35,998	0	0	0	0
Annual Time Burden (Hours)	54,426	44,363	0	10,063	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: The COVID-19 items are estimated to add 15 minutes to the Community and Facility instruments each round starting in 2021; in addition, 1 minute of burden will be added to each Fall interview beginning in Fall 2021 Round 91 due to the addition of 3 new questions, 2 on housing insecurity and 1 on social isolation. Last, the burden reflects the one-time collection of COVID-19 questions (15 minutes per interview) for the NGACO sample. As a result, the total burden has increased to 54,426 from the previously approved total burden of 44,363. This is a net increase of 10,063 burden hours annually.

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Annual Cost to Federal Government: $24,215,710

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? 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: 12/10/2020

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