Information Collection

MA-Only CAHPS Field Test Survey

IC 251370 under ICR 202201-0938-021 · OMB 0938-1432.

Documents and Forms

Document Name Document Type
Form CMS-10793 MA-Only CAHPS Field Test Survey Form and Instruction
CMS-10793 2022 Medicare Advantage Plan Survey Field Test Version 2022 MA-Only Field Test Survey_1-26-22.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MA-Only CAHPS Field Test Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Part 422 Section 152 42 CFR Part 423 Section 156 42 CFR Part 417 Section 472 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10793	2022 Medicare Advantage Plan Survey Field Test Version	2022 MA-Only Field Test Survey_1-26-22.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Health Plan Management System (HPMS)	FR Citation: 83 FR 6591

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.