List of Screening Instruments for Housing Stability, Food Security, and Transportation Questions on Health Risk Assessments (CMS-10825)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10825_HRA SDOH Guidance.docx	Supplementary Document	Uploaded 2023-02-07	Repair queued
CMS-10825_Crosswalk of updates to HRA SDOH guidance.docx	Supplementary Document	Uploaded 2023-02-07	Repair queued
CMS-10825 Response to Public Comments.docx	Supplementary Document	Uploaded 2023-02-07	Repair queued
CMS-10825 Supporting Statement_30 Day Package.docx	Supporting Statement A	Uploaded 2023-02-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
258371	§ 422.101 - Registration for VSAC Username	Instruction	New
258370	§ 422.101 - Update HRA System	Instruction	New

ICR Details

OMB Control No: 0938-1446	ICR Reference No: 202302-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: List of Screening Instruments for Housing Stability, Food Security, and Transportation Questions on Health Risk Assessments (CMS-10825)
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 without change	Conclusion Date: 06/20/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/07/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved
Responses	174	0	0
Time Burden (Hours)	167	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request is for the new regulation at 42 CFR 422.101(f)(1)(i) requiring that all MA SNP health risk assessments (HRAs) include at least one question from a list of screening instruments specified by CMS in sub-regulatory guidance on each of three domains (housing stability, food security, and access to transportation) beginning in CY 2024. This new requirement will help better identify the risk factors that may inhibit enrollees from accessing care and achieving optimal health outcomes and independence and enable MA SNPs to take these risk factors into account in enrollee individualized care plans. This information collection request provides the list of CMS-specified social determinants of health (SDOH) screening instruments available for SNPs to meet the new requirement.

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Authorizing Statute(s): US Code: 42 USC 42 U.S.C. 1395w–28 Name of Law: Section 1859(f)(5)(A)(ii)(I) of the SSA
  

Citations for New Statutory Requirements: US Code: 42 USC 42 U.S.C. 1395w–28 Name of Law: Section 1859(f)(5)(A)(ii)(I) of the SSA

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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 65207	10/28/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 7731	02/06/2023
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
§ 422.101 - Registration for VSAC Username
§ 422.101 - Update HRA System

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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	174	0	174	0	0	0
Annual Time Burden (Hours)	167	0	167	0	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: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $2,054

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: 02/07/2023

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