SUPPORTING STATEMENT – Part A
Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of
Healthcare Providers and Systems (CAHPS) Survey
CMS-R-246, OMB 0938-0732
The Centers for Medicare & Medicaid Services (CMS) has authority to collect various types of quality data under section 1852(e) of the Act and use this information to develop and publicly post a 5-star rating system for Medicare Advantage (MA) plans based on its authority to disseminate comparative information, including about quality, to beneficiaries under sections 1851(d) and 1860D-1(c) of the Act. As codified at § 422.152(b)(3), Medicare health plans are required to report on quality performance data which CMS can use to help beneficiaries compare plans. Cost plans under section 1876 of the Act are also included in the MA Star Rating system, as codified at § 417.472(k), and are required by regulation (§ 417.472(j)) to make CAHPS survey data available to CMS.
Based on requirements in the 2003 Medicare Prescription Drug Improvement and
Modernization Act (MMA), CMS has collected information about the experiences of MA and Medicare Prescription Drug Plan (PDP) enrollees with their plans through the annual implementation of the CAHPS survey since 2006. Earlier, requirements in the Balanced Budget Act of 1997 also required CMS to collect and report satisfaction and quality information about the Medicare health plans available under the Medicare + Choice plans and the Medicare Fee For-Service (FFS) program and to provide this information to Medicare enrollees to assist them in their selection of a Medicare plan. The CAHPS survey for health plans has been collected since 1997, and the Medicare FFS survey has been collected since 2000.
The MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys of enrollees in MA and Part D contracts and report the results to Medicare beneficiaries prior to the annual enrollment period. This request for approval is to update the annual Medicare CAHPS surveys to meet the requirement to conduct consumer satisfaction surveys regarding the experiences of beneficiaries with their health and prescription drug plans.
This information collection request includes the CAHPS data collection requirements set forth in the Part C and D final rule published on January 22, 2009. The final rule set forth this requirement under § 422.152(b)(5) for Part C, § 417.472(j) for section 1876 cost contracts, and § 423.156 for Part D. CMS will continue to administer the Medicare FFS CAHPS survey.
CMS approves and trains survey vendors to collect and submit data on behalf of the MA, section 1876 cost, and Part D contracts. All contracts that are required to conduct CAHPS need to contract directly with an approved vendor. CMS is responsible for approving and training
1
vendors, providing technical assistance to vendors, overseeing vendors to ensure that they are following the data collection protocols, providing the samples directly to the survey vendors, collecting and analyzing the data for public reporting, and producing reports that the plans can use for quality improvement.
We have made several changes to the FFS, MA-Only, MA-PD, and PDP surveys. For all surveys, we have added a question to capture what language is mainly spoken at home. For FFS, MA-Only, and MA-PD, we have adopted AHRQ’s 5.1 Health Plan Survey wording clarifications for explicit references to care received via telehealth (phone or video) and added a question about unfair treatment. For FFS only, we have added three questions related to sexual orientation and gender identity and removed five questions that ask about the Medicare Part D Medication Therapy Management program. For MA-Only, MA-PDP, and PDP surveys, we have removed a question about receiving mail order medicines. The survey changes are documented in the respective crosswalks submitted with this package. These changes do not affect the time for Medicare beneficiaries to complete a CAHPS survey. The requirements and burden for MA and PDP contracts are unchanged.
A. JUSTIFICATION
CMS is required to collect and report information on the quality of health care services and prescription drug coverage available to persons enrolled in a Medicare health or prescription drug plan under provisions in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA). Specifically, the MMA under Sec. 1860D-4 (Information to
Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys regarding
Medicare prescription drug plans and Medicare Advantage plans and report this information to Medicare beneficiaries prior to the Medicare annual enrollment period. The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. The Balanced Budget Act of 1997 also requires the collection of information about fee-for-service plans. The CAHPS survey measures are incorporated into the Part C and D Star
Ratings that are published on www.medicare.gov each fall to help consumers choose a
Medicare plan. A subset of the CAHPS measures is also included in the Medicare & You Handbook. CAHPS information from MA contracts also feeds into the calculation of MA Quality Bonus Payment Ratings that are required by statute and regulation.
The primary purpose of the Medicare CAHPS surveys is to provide information to Medicare beneficiaries to help them make more informed choices among health and prescription drug plans available to them. Survey results are reported by CMS in the Medicare & You Handbook published each fall and on the Medicare Plan Finder website. Beneficiaries can compare CAHPS scores for each health and drug plan as well as compare MA and FFS scores when making enrollment decisions. The Medicare CAHPS also provides data to help CMS and others monitor the quality and performance of Medicare health and prescription drug plans and identify areas to improve the quality of care and services provided to enrollees of these plans. CAHPS data are included in the Medicare Part C & D Star Ratings and used to calculate MA Quality Bonus Payments.
There are no barriers or obstacles that prohibit the use of improved technology for this information collection activity. CMS will provide approved CAHPS vendors with the samples of enrollees for their client plans. The data collection protocol is mixed mode. Traditionally, these surveys have used mail with telephone follow-up of non-respondents, but we are planning to introduce a web mixed mode that includes web with mail and telephone follow-up of non-respondents for the 2024 survey administration.: Sampled enrollees will be surveyed using a web-first protocol in which web is the initial mode of survey administration. Sampled enrollees with an available email address will receive an email invitation to complete the survey and those without an available email address will receive a letter with a personalized URL to complete the survey online. Those who do not respond by web will receive up to two mailings of a paper survey; those who do not respond by web or mail will receive up to five attempts to complete the survey by phone.
The health plan section of the survey that CMS is conducting is the same survey that is required by the National Committee for Quality Assurance (NCQA) for accreditation of Medicare health plans; thus, there is no duplication of effort. It is also similar to the surveys used for commercial and Medicaid plans. The sampling for the MA & PDP CAHPS survey allows for reliable estimates for MA and PDP plans at the contract level. Other surveys, such as the Medicare Current Beneficiary Survey (MCBS), cannot be used to evaluate performance of MA and PDP plans given they cannot produce reliable estimates of plan performance.
Survey respondents are Medicare Advantage (MA with or without a Prescription Drug Plan), Medicare Fee-For-Service (FFS), or Medicare Stand Alone Prescription Drug Plan (PDP) enrollees. Both MA and PDP contracts pay for the data collection using vendors approved by
CMS. The cost of conducting the CAHPS survey for each contract is estimated to be approximately $5,300. The survey instruments and procedures for completing the instruments are designed to minimize burden on all respondents and will not have a significant impact on small businesses or other small entities.
The Medicare CAHPS survey is conducted annually. CMS is required to provide up-to-date information to Medicare beneficiaries each year prior to the annual enrollment period to help them make more informed plan choices. Additionally, the information is used by CMS for monitoring of plan quality and by plans to improve the health care and services they provide to their enrollees. Given the uses of the data and the need to have these data for MA Quality Bonus Payments, it is important that persons with Medicare, CMS, and others have current information about the experiences of persons enrolled in Medicare health and prescription drug plans. Provision of this information on an annual basis allows for the design of quality improvement initiatives on a timely basis and helps inform beneficiaries about the quality and performance of health and prescription drug plans at the time they make a health or drug plan selection each year.
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
-Report information to the agency more often than quarterly;
-Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
-Submit more than an original and two copies of any document;
-Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
-Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;
-Use a statistical data classification that has not been reviewed and approved by OMB;
-Include a pledge of confidentiality that is not supported by authority established in statue or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
-Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
The 60-day Federal Register Notice published in the Federal Register (88 FR 7976) on 01/07/2023. A total of three comments were received for the 60-day comment period and responses were provided within the attached Response to Comments document. Most commenters expressed support for the addition of a web mode and the survey revisions. A few comments suggested alterative or additional survey questions. Two comments made suggestions for the web mode implementation.
The 30-day Federal Register Notice published in the Federal Register (88 FR 28554) on 05/04/2023.
Respondents do not receive any payments or gifts for their participation. Data collected provides all Medicare beneficiaries with information to help them make more informed choices among health and prescription drug plans available to them.
Individuals and organizations contacted are assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR parts 401 and 422, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130. In instances where respondent identity is needed, the information collection fully complies with all respects of the Privacy Act. The System of Records is HPMS No. 09-70-4004 (January 14, 2008; 73 FR 2257).
Sensitive questions related to sexual orientation and gender identity have been added to the FFS CAHPS Survey. Given the importance of health equity, CMS wants to understand if experiences differ by sexual orientation and gender identity. To determine if there are any issues with implementation of these questions, we are adding to only the FFS CAHPS survey first. We will track and evaluate any implementation issues before adding these questions to other surveys. Survey respondents are able to skip any questions that they do not wish to answer.
12. Burden Estimate (Hours & Wages)
To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’
May 2021 National Occupational Employment and Wage Estimates for our salary estimate
(www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $28.01/hour since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, educational attainment, etc.
We are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.
The Medicare CAHPS survey is conducted annually. The CAHPS survey takes on average 13 minutes to complete. This burden varies by survey type as shown below. For the total sample of 794,500 members, the total burden to complete the survey is approximately the sum of MA0 (0.25 hours x 750,090), PDP (0.17 hours x 79,500), and FFS Medicare (0.25 x 275,000) or 192,265 hours.
The reason for the variation in burden hours by survey type is that the CAHPS survey has specific questions relevant to the Medicare plan in which a sample member is enrolled, i.e., MA-Only, MA-PD, PDP, or FFS. Sample size for the PDP survey is 1,500 to improve reliability, and the sample size for FFS is needed for refined comparisons with MA.
Time
Survey Type |
Units |
Sample/Unit |
Sample by Type |
Burden/Survey |
Total Hours |
MA |
550 |
800 |
440,000 |
0.25 |
110,000 |
PDP |
53 |
1,500 |
79,500 |
0.17 |
13,515 |
FFS |
78 |
3,525 |
275,000 |
0.25 |
68,750 |
TOTAL |
- |
- |
794,500 |
- |
192,265 |
Cost
Survey Type |
Number of Respondents |
Total Burden Hours |
Average Hourly Wage |
Estimated Data Collection Cost to Respondents |
MA |
440,000 |
110,000 |
$28.01/hr |
$3,081,100 |
PDP |
79,500 |
13,515 |
$28.01/hr |
$378,555 |
FFS |
275,000 |
68,750 |
$28.01/hr |
$1,925,687 |
Total |
794,500 |
192,265 |
$28.01/hr |
$5,385,342 |
MA-Only Survey
MA-PD Survey
PDP Survey
FFS Survey
The cost to Medicare MA and PDP contracts is the cost of their contracting with Medicare CAHPS vendors approved by CMS to pay for the data collection for the sample of Medicare enrollees in their respective contracts that CMS provides to the vendors. CMS estimates this cost is about $5,300 per contract at the contract level, although the final cost is dependent on the negotiated contracts that the MA/PDP contracts execute with CAHPS approved vendors for their data collection. CMS is estimating that there are 603 MA/PDP contracts that are impacted by this small cost. We estimate a total cost of $3,195,900.
The total cost to the Federal government for the Medicare CAHPS Surveys is estimated to be $7 million each year. This total includes CMS management and implementation of the Medicare FFS data collection; approval process for survey vendors; training, oversight, and technical assistance of the approved survey vendors for the MA and PDP contracts; preparation and cleaning of data submitted by the survey vendors for the MA and PDP contracts; data analysis; preparation of CAHPS measures for public reporting; and production of plan reports to be used by all participating MA and PDP plans for quality improvement.
The FFS, MA-Only, MA-PD and PDP surveys have been updated as documented in the respective Crosswalks attached to this package. The updates to the MA, FFS, and PDP CAHPS surveys and survey administration would allow CMS to be responsive to stakeholder feedback regarding the mode of administration and survey content. It will also allow CMS to address priorities around health equity by collecting data to inform the agency if there are existing health disparities that need to be addressed. Specifically, stakeholder feedback and CMS priorities will be addressed through the following changes:
Addition of a web mode (all surveys) - Commenters to the 2023 Advance Notice overwhelmingly supported the addition of a web mode for the MA and PDP CAHPS survey as part of the mixed mode data collection protocol. The web mode was tested under CMS-10793, OMB 0938-1432 and was found to increase MA response rates by four percentage points.
Addition of question regarding language spoken at home (all surveys) – The addition of this question will help CMS determine if additional case mix adjustments are needed. It would also assist CMS in measuring health equity.
Adoption of AHRQ’s 5.1 Health Plan Survey wording clarifications (MA-PD, MA-Only, and FFS) - The 5.1 clarifications explicitly added references to in-person, phone, or video appointments to a few of the CAHPS survey items asking about health care experiences. In testing under OMB 0938-1432 we did not find evidence that the 5.1 changes affect scores on the CAHPS Star Ratings measures.
Addition of question on unfair treatment (MA-PD, MA-Only, and FFS) - The question on unfair treatment asks whether in the last 6 months anyone from a clinic, emergency room, or doctor’s office treated the enrollee in an unfair or insensitive way because of their health condition, disability, age, culture or religion, language or accent, race or ethnicity, sex (female or male), sexual orientation, gender or gender identity, or income. While few enrollees reported experiencing unfair treatment overall, unfair treatment by health condition was most common, followed by unfair treatment by disability and age. Across MA contracts in the field test, 9.4 percent of respondents endorsed one or more reasons for being treated in an unfair or insensitive way. This question would assist CMS in measuring health equity and would provide contracts with information for quality improvement.
Addition of questions about sexual orientation and gender identity – The questions on sexual orientation and gender identity ask the respondent about their sex assigned at birth, their current gender, and how they describe their sexuality. Given the importance of health equity, CMS wants to understand if experiences differ by sexual orientation and gender identity. These questions would only be added to the FFS Survey at this time to obtain experience collecting this information prior to including it on multiple surveys.
Removal of questions about the Medicare Part D Medication Therapy Management program and receipt of mail order medicines not requested due to them becoming unreliable as only relevant for a small number of enrollees.
These changes do not affect the time for Medicare beneficiaries to complete a CAHPS survey. However, we have increased the estimated burden from the currently approved estimate of 179,108 hours to 192,265 due to an increase in the number of MA contracts (increase of 13,157 hours) and slight increase in the FFS sample size (increase of 12 hours). The number of PDP contracts decreased by one.
The CAHPS survey results are disseminated through tools on www.medicare.gov – Medicare
Plan Finder – that contain comparative information on prescription drug and health plans. The Medicare & You Handbook also contains some CAHPS information and instructions about how to obtain information on additional measures. The information is made available in the fall following each annual data collection, prior to the annual enrollment period.
Medicare health and prescription drug plans also receive plan-specific reports that contain detailed information on the CAHPS results for their plan for use in quality improvement initiatives. These reports include background information on the methodology and definitions used in CAHPS to assist them in understanding the information in their report.
The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. MA & PDP CAHPS survey measures are incorporated into the Part C & D Star Ratings that are published on www.medicare.gov each fall for consumers. A subset of the CAHPS measures are also included in the Medicare & You Handbook.
The OMB Number and expiration date will be displayed on the survey. No exemption is being requested.
There are no exceptions taken to item 19 of OMB Form 83-1.
0 We have combined estimates for MA-Only and MA-PD survey versions here for simplicity.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CMS-R-246 MA FFS PDP CAHPS OMB SUPPORTING STATEMENT A |
| Author | Stephan McKenzie |
| File Modified | 0000-00-00 |
| File Created | 2023-08-08 |