CMS-R-246 - Supporting Statement A

SUPPORTING STATEMENT – Part A

Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of

Healthcare Providers and Systems (CAHPS) Survey

(CMS-R-246, OMB 0938-0732)

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) has authority to collect various types of quality data under section 1852(e) of the Act and use this information to develop and publicly post a 5-star rating system for Medicare Advantage (MA) plans based on its authority to disseminate comparative information, including about quality, to beneficiaries under sections 1851(d) and 1860D-1(c) of the Act. As codified at § 422.152(b)(3), Medicare health plans are required to report on quality performance data which CMS can use to help beneficiaries compare plans. Cost plans under section 1876 of the Act are also included in the MA Star Rating system, as codified at § 417.472(k), and are required by regulation (§ 417.472(j)) to make CAHPS survey data available to CMS.

Based on requirements in the 2003 Medicare Prescription Drug Improvement and

Modernization Act (MMA), CMS has collected information about the experiences of MA and Medicare Prescription Drug Plan (PDP) enrollees with their plans through the annual implementation of the CAHPS survey since 2006. Earlier, requirements in the Balanced Budget Act of 1997 also required CMS to collect and report satisfaction and quality information about the Medicare health plans available under the Medicare + Choice plans and the Medicare Fee For-Service (FFS) program and to provide this information to Medicare enrollees to assist them in their selection of a Medicare plan. The CAHPS survey for health plans has been collected since 1997, and the Medicare FFS survey has been collected since 2000.

The MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys of enrollees in MA and Part D contracts and report the results to Medicare beneficiaries prior to the annual enrollment period. This request for approval is for CMS to continue conducting the Medicare CAHPS surveys annually to meet the requirement to conduct consumer satisfaction surveys regarding the experiences of beneficiaries with their health and prescription drug plans.

This information collection request includes the CAHPS data collection requirements set forth in the Part C and D final rule published on January 22, 2009. The final rule set forth this requirement under § 422.152(b)(5) for Part C, § 417.472(j) for section 1876 cost contracts, and § 423.156 for Part D. CMS will continue to pay for the data collection costs for the Medicare FFS CAHPS survey.

CMS approves and trains survey vendors to collect and submit data on behalf of the MA, section 1876 cost, and Part D contracts. All contracts that are required to conduct CAHPS need to contract directly with an approved vendor. CMS is responsible for approving and training

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vendors, providing technical assistance to vendors, overseeing vendors to ensure that they are following the data collection protocols, providing the samples directly to the survey vendors, collecting and analyzing the data for public reporting, and producing reports that the plans can use for quality improvement.

We have made one change to the FFS, MA-Only, MA-PD, and PDP surveys: an update to the re-contact question. The update clarifies the reasons CMS may re-contact a beneficiary who responded to the survey. This change does not affect the time for Medicare beneficiaries to complete a CAHPS survey. The requirements and burden for MA and PDP contracts are unchanged.

A. JUSTIFICATION

1. Need and Legal Basis

CMS is required to collect and report information on the quality of health care services and prescription drug coverage available to persons enrolled in a Medicare health or prescription drug plan under provisions in the Medicare Prescription Drug, Improvement, and

Modernization Act of 2003 (MMA). Specifically, the MMA under Sec. 1860D-4 (Information to

Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys regarding

Medicare prescription drug plans and Medicare Advantage plans and report this information to Medicare beneficiaries prior to the Medicare annual enrollment period. The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. The CAHPS survey measures are incorporated into the Star Ratings that are published on www.medicare.gov each fall for consumers. A subset of the CAHPS measures are also included in the Medicare & You Handbook.

2. Information Users

The primary purpose of the Medicare CAHPS surveys is to provide information to Medicare beneficiaries to help them make more informed choices among health and prescription drug plans available to them. Survey results are reported by CMS in the Medicare & You handbook published each fall and on the Medicare Plan Finder website. Beneficiaries can compare CAHPS scores for each health and drug plan as well as compare MA and FFS scores when making enrollment decisions. The Medicare CAHPS also provides data to help CMS and others monitor the quality and performance of Medicare health and prescription drug plans and identify areas to improve the quality of care and services provided to enrollees of these plans. CAHPS data are included in the Medicare Part C & D Star Ratings and used to calculate MA Quality Bonus Payments. The Star Ratings program has led to health and drug plan quality improvement. For example, the average enrollment-weighted overall Star Rating for MA-PD contracts has increased from 3.92 in 2015 to 4.16 in 2020. In 2015 approximately 60% of MA-PD enrollees were in contracts with 4 or more stars; this has increased to 81% of enrollees in 2020.

3. Use of Improved Information Technology

There are no barriers or obstacles that prohibit the use of improved technology for this information collection activity. CMS will provide approved CAHPS vendors with the samples of enrollees for their client plans. The data collection protocol is mixed mode (mail with telephone follow-up of non-respondents).

4. Duplication of Efforts

The health plan section of the survey that CMS is conducting is the same survey that is required by the National Committee for Quality Assurance (NCQA) for accreditation of Medicare health plans; thus, there is no duplication of effort.

5. Small Business

Survey respondents are Medicare Advantage (MA with or without a Prescription Drug Plan), Medicare Fee-For-Service (FFS), or Medicare Stand Alone Prescription Drug Plan (PDP) enrollees. Both MA and PDP contracts pay for the data collection using vendors approved by CMS. The cost of conducting the CAHPS survey for each contract is estimated to be approximately $5,300. The survey instruments and procedures for completing the instruments are designed to minimize burden on all respondents and will not have a significant impact on small businesses or other small entities.

6. Less Frequent Collection

The Medicare CAHPS survey is conducted annually. CMS is required to provide up-to-date information to Medicare beneficiaries each year prior to the annual enrollment period to help them make more informed plan choices. Additionally, the information is used by CMS for monitoring of plan quality and by plans to improve the health care and services they provide to their enrollees. Given the uses of the data, it is important that persons with Medicare, CMS, and others have current information about the experiences of persons enrolled in Medicare health and prescription drug plans. Provision of this information on an annual basis allows for the design of quality improvement initiatives on a timely basis and helps inform beneficiaries about the quality and performance of health and prescription drug plans at the time they make a health or drug plan selection each year.

7. Special Circumstances

There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:

-Report information to the agency more often than quarterly;

-Prepare a written response to a collection of information in fewer than 30 days after receipt of it; -Submit more than an original and two copies of any document;

-Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

-Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

-Use a statistical data classification that has not been reviewed and approved by OMB;

-Include a pledge of confidentiality that is not supported by authority established in statue or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

-Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. Federal Register/Outside Consultation

The 60-day Federal Register Notice published in the Federal Register on 11/09/2020 (85 FR 71344). Comments were received and are attached to this package along with our response. Several commenters were concerned the CAHPS questionnaire will not accurately capture their members’ experiences with phone or video visits; CMS agrees that the survey instructions should be modified to ask beneficiaries to consider in-person, phone, and video visits; we have made that change in the instruments.

The 30-day Federal Register Notice published in the Federal Register on 2/5/2021 (86 FR 8361).

9. Payment/Gifts to Respondents

Respondents do not receive any payments or gifts for their participation. Data collected provides all Medicare beneficiaries with information to help them make more informed choices among health and prescription drug plans available to them.

10. Confidentiality

Individuals and organizations contacted are assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR parts 401 and 422, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130. In instances where respondent identity is needed, the information collection fully complies with all respects of the Privacy Act. The System of Records is HPMS No. 09-70-4004 (January 14, 2008; 73 FR 2257).

11. Sensitive Questions

There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Burden Estimate (Hours & Wages)

Wage Estimates

To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’

May 2019 National Occupational Employment and Wage Estimates for our salary estimate

(www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $25.72/hour since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, educational attainment, etc.

We are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.

Burden Estimates

The Medicare CAHPS survey is conducted annually. The CAHPS survey takes on average 13 minutes to complete. This burden varies by survey type as shown below. For the total sample of 745,350 members, the total burden to complete the survey is approximately the sum of MA⁰ (0.25 hours x 386,400), PDP (0.17 hours x 81,000), and FFS Medicare (0.25 x 274,950) or 179,108 hours.

The reason for the variation in burden hours by survey type is that the CAHPS survey has specific questions relevant to the Medicare plan in which a sample member is enrolled, i.e., MA-Only, MA-PD, PDP, or FFS. Sample size for PDP survey is 1,500 to improve reliability, and the sample size for FFS is needed for refined comparisons with MA.

Time

Sample by Total

Survey Type	Units	Sample/Unit	Type	Burden/Survey	Hours
MA	483	800	386,400	0.25	96,600
PDP	54	1,500	81,000	0.17	13,770
FFS	78	3,525	274,950	0.25	68,738
TOTAL	-	-	745,350	-	179,108

Cost

Estimated

Data

Total Average Collection Cost

Number of Burden Hourly to Survey Type Respondents Hours Wage Respondents

MA	386,400	96,600 $25.72/hr	$2,484,552.00
PDP	81,000	13,770 $25.72/hr	$354,164.40
FFS	274,950	68,738 $25.72/hr	$1,767,941.36
Total	742,350	179,108 $25.72/hr	$4,606,657.76

Information Collection Instruments and Instruction/Guidance Documents

• MA-Only Survey

• MA-PD Survey

• 
  PDP Survey

• FFS Survey

13. Capital Costs

The cost to Medicare MA and PDP contracts is the cost of their contracting with Medicare CAHPS vendors approved by CMS to pay for the data collection for the sample of Medicare enrollees in their respective contracts that CMS provides to the vendors. CMS estimates this cost is about $5,300 per contract at the contract level, although the final cost is dependent on the negotiated contracts that the MA/PDP contracts execute with CAHPS approved vendors for their data collection. CMS is estimating that there are 537 MA/PDP contracts that are impacted by this small cost. We estimate a total cost of $2,846,100.

14. Cost to Federal Government

The total cost to the Federal government for the Medicare CAHPS Surveys is estimated to be $7 million each year. This total includes CMS management and implementation of the Medicare FFS data collection; approval process for survey vendors; training, oversight, and technical assistance of the approved survey vendors for the MA and PDP contracts; preparation and cleaning of data submitted by the survey vendors for the MA and PDP contracts; data analysis; preparation of CAHPS measures for public reporting; and production of plan reports to be used by all participating MA and PDP plans for quality improvement.

15. Changes to Burden

The re-contact question in the FFS, MA-Only, MA-PD and PDP surveys has been updated as documented in the respective Crosswalks attached to this package. We also modified the survey instructions to ask beneficiaries to consider in-person, phone, and video visits. These changes do not affect the time for Medicare beneficiaries to complete a CAHPS survey.

However, we have reduced the estimated burden from the currently approved estimate of 192,113 hours to 179,108 hours due to a smaller number of MA and PDP contracts (decrease of 13,005 hours).

16. Publication/Tabulation Dates

The CAHPS survey results are disseminated through tools on www.medicare.gov – Medicare

Plan Finder – that contain comparative information on prescription drug and health plans. The Medicare & You Handbook also contains some CAHPS information and instructions about how to obtain information on additional measures. The information is made available in the fall following each annual data collection, prior to the annual enrollment period.

Medicare health and prescription drug plans also receive plan-specific reports that contain detailed information on the CAHPS results for their plan for use in quality improvement initiatives. These reports include background information on the methodology and definitions used in CAHPS to assist them in understanding the information in their report.

The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. MA & PDP CAHPS survey measures are incorporated into the Part C & D Star Ratings that are published on www.medicare.gov each fall for consumers. A subset of the CAHPS measures are also included in the Medicare & You Handbook.

17. Expiration Date

No exemption is being requested.

18. Certification Statement

There are no exceptions taken to item 19 of OMB Form 83-1.

0 We have combined estimates for MA-Only and MA-PD survey versions here for simplicity.