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 0938-0568_SSA.docx	Supporting Statement A	Uploaded 2022-04-04	Repair queued
2023 Full Clearance 30-Day Crosswalk.docx	Supplementary Document	Uploaded 2022-04-04	Repair queued
CMS-P-0015A_0938-0568_SSB.docx	Supporting Statement B	Uploaded 2022-04-04	Repair queued
Responses to Public Comments.docx	Supplementary Document	Uploaded 2022-03-29	Repair queued
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
HCStatementGPLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
FacThankYouLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
FacPrepInterviewLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
FacAdvLetterBillOffices.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
ComLanguageInsert.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
BaseThankYouLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
BaseFAQEnclosure.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
AdvLetterFAQEnclosure.pdf	Supplementary Document	Uploaded 2022-03-29	Missing upstream
Att8.LGBTSumryReportFinal.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
ComAdvLetterCallUs.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
Attachment 7. 2023 Testing Report.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
CMSThankYouLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
Reminder Postcard_Phone.docx	Supplementary Document	Uploaded 2020-11-23	Missing upstream
ReminderPostcard.pdf	Supplementary Document	Uploaded 2022-03-29	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
ReminderLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
NonResponseLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
IncomeandAssetsBrochure.pdf	Supplementary Document	Uploaded 2022-03-29	Missing upstream
Community Brochure_Phone_English.pdf	Supplementary Document	Uploaded 2020-11-23	Repair queued
MCBSCommunityBrochure.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
Community Authority Letter_NGACO.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
CommunityAuthLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Missing upstream
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2022-03-29	Missing upstream
Community Advance Letter_NGACO.docx	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	Repair queued
FacAdvanceLetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
Attachment 6. CAPI screenshots.docx	Supplementary Document	Uploaded 2022-03-29	Repair queued
NextofKinForm.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
ResConsentForm.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
HIPAALetter.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
Refusal Letter_Com_Continuing Rs_Eng_FM800.doc	Supplementary Document	Uploaded 2019-04-16	Repair queued
AtDoorSheet.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
MCBSCalendar.PDF	Supplementary Document	Uploaded 2022-03-29	Repair queued
RespondentNewsletter.pdf	Supplementary Document	Uploaded 2022-03-29	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: 202203-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202105-0938-001
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: 04/04/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/29/2024
Responses	35,998	35,998
Time Burden (Hours)	46,680	54,426
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:
	87 FR 3301	01/22/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 19517	04/04/2022
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 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, P-0015A, 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	Cost Payment Summary ,   Demographic Income ,   End Questionaire ,   Enumeration Summary ,   Home Health Summary ,   interviewer Remarks ,   Mobility of Beneficiaries ,   Post Statement Cost ,   Access to Care ,   Chronic Pain ,   Dental, Vision, and Hearing Care Utilization ,   Drug Coverage ,   Emergency Utilization ,   Health Insurance ,   Home Health ,   Housing_Characteristics ,   Income_and_ Assets ,   Inpatient Utilization ,   Institutional Utilization ,   Introduction ,   Medical Provider Utilzation ,   Nicotine Alcohol ,   No Statement Cost ,   Other Medical Expense ,   Outpatient Utilization ,   Prescribed Medicine Utilization ,   Satisfaction Care ,   Statement Cost Series ,   Beneficiary Knowledge ,   Preventive Care ,   Usual Source of Care ,   Showcards and Reference Cards ,   Facility Showcards ,   Facility Screener ,   Residence History Missing Data ,   Residence History ,   Use of Health Services ,   Background_Questionnaire ,   Background_Questionnaire MIssing Data ,   Expenditures ,   Questionaire Missing Data ,   Questionaire ,   Health_Insurance ,   Health_Status ,   Cognitive Measures ,   Health Status and Functioning Questionnaire Specification ,   Physical_Measures ,   interviewer Remarks ,   COVID-19 Questionnaire Specifications ,   COVID-19 Facility-Level Supplement ,   CV-COVID-19 Beneficiary Supplement ,   Use of Health Services Section Specifications ,   Telemedicine 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	35,998	35,998	0	0	0	0
Annual Time Burden (Hours)	46,680	54,426	0	-7,746	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden has decreased due to deletions to the Community and Facility instruments related to COVID-19 content that is no longer relevant for administration. The estimated respondent burden is also updated to reflect the impact of the additional content and the offset by the deletion of some COVID-19 content. As a result, the total burden has decreased to 46,575 from the previously approved total burden of 54,426. This is a net decrease of 7,851 burden hours annually.

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Annual Cost to Federal Government: $20,880,830

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: 04/04/2022

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