Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10816 Cognitive Interview Protocol	Form and Instruction	New	Available
Form CMS-10816 Informed Consent	Form and Instruction	New	Available
Form CMS-10816 Interview Guide	Form and Instruction	New	Repair queued
Form CMS-10816 Eligibility Screener Questionnaire	Form and Instruction	New	Available
Form CMS-10816 Recruitment Script	Form and Instruction	New	Available
Form CMS-10816 Invitation & Screening	Form and Instruction	New	Repair queued
CMS-10816 - Supporting Statement A.docx	Supporting Statement A	Uploaded 2022-11-29	Repair queued
CMS-10816 - Supporting Statement B.docx	Supporting Statement B	Uploaded 2022-11-28	Repair queued
CMS Response to CMS-10816 60-day Public Comments 11.14.22 Final.docx	Supplementary Document	Uploaded 2022-11-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
257119	Interview Guide	Form and Instruction	New	Cognitive Interview Protocol
257119	Interview Guide	Form and Instruction	New	Informed Consent
257119	Interview Guide	Form and Instruction	New
257116	Invitation & Screening	Form and Instruction	New	Eligibility Screener Questionnaire
257116	Invitation & Screening	Form and Instruction	New	Recruitment Script
257116	Invitation & Screening	Form and Instruction	New

ICR Details

OMB Control No: 0938-1440	ICR Reference No: 202211-0938-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMC-CPC
Title: Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/14/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/29/2022
Terms of Clearance: Within 90 days of approval of this ICR, CMS is required to survey its other ICR packages and submit non-substantial change requests to revise its new racial question. This revision will ensure appropriate and tested alphabetization of racial categories with nested sub-categories of race rather than alphabetization of all sub-categories together. Also "other" sub-categories should be at the bottom of the sub-category list such as "other Asians." CMS is encouraged to follow-up if it needs additional guidance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	36 Months From Approved
Responses	470	0	0
Time Burden (Hours)	114	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CMS’ primary objective for the interviews is to identify the drivers of nonresponse to the race and ethnicity questions. Specifically, we aim to solicit detail on whether and what concerns drove individuals’ nonresponse to these items, including (but not limited to) (a) concerns about confidentiality of their data, (b) concerns about how their race and ethnicity data would be used, including concerns about whether disclosing such information could in any way affect eligibility for Medicare benefits (which it would not), or (c) concerns about response options (e.g. missing response options for race or ethnicity groups in which they may identify). We also intend to explore whether it is possible to amend the race and ethnicity elements on Part C/D enrollment form to address any of those concerns, and if so, how. Additionally, we plan to ask whether there are other – beyond the Part C/D enrollment form – vehicles for collecting race and ethnicity information that would be more acceptable to non-responders, and if so, what those are.

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Authorizing Statute(s): PL: Pub.L. 105 - 33 Sec 4001 Name of Law: Balanced Budget Act of 199
   PL: Pub.L. 108 - 173 Sec. 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
  

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 51675	08/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 72485	11/25/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Interview Guide	CMS-10816, CMS-10816	Informed Consent ,   Cognitive Interview Protocol
Invitation & Screening	CMS-10816, CMS-10816	Recruitment Script ,   Eligibility Screener Questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	470	0	0	0	470	0
Annual Time Burden (Hours)	114	0	0	0	114	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $122,904

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.     Yes

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: 11/29/2022

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