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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
MBECS Supporting Statement Part A_.docx	Supporting Statement A	Uploaded 2021-07-29	Repair queued
Attachment A - MBECS questionnaire.pdf	Supplementary Document	Uploaded 2021-07-29	Repair queued
MBECS Screenshots.pdf	Supplementary Document	Uploaded 2021-07-29	Repair queued
OMH Response and Comments Summary.docx	Supplementary Document	Uploaded 2021-07-29	Repair queued
MBECS Supporting Statement Part B_.docx	Supporting Statement B	Uploaded 2021-07-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form

ICR Details

OMB Control No:	ICR Reference No: 202107-0938-016
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: 07/30/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	13,000	0
Time Burden (Hours)	4,290	0
Cost Burden (Dollars)	232,260	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): US Code: 42 USC 300kk Name of Law: Data collection, analysis, and quality
  

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:
	86 FR 18534	04/09/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 40846	07/29/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 0

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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	13,000	0	0	0	13,000	0
Annual Time Burden (Hours)	4,290	0	0	0	4,290	0
Annual Cost Burden (Dollars)	232,260	0	0	0	232,260	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: $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: 07/30/2021

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