Beneficiary and Family Centered Data Collection (CMS-10393)

Forms and Documents

Document Name	Status
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey Form and Instruction	Modified
CMS-10393_Supporting Statement-Part_B_06.29.2023.docx Supporting Statement B	2023-10-27
CMS-10393_Supporting Statement_Part_A_06.29.2023.docx Supporting Statement A	2023-10-27

IC Document Collections

IC ID	Document Title	Status
201543	Medicare Beneficiary and Family-Centered Satisfaction Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1177	ICR Reference No: 202310-0938-005
Status: Received in OIRA	Previous ICR Reference No: 202010-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Beneficiary and Family Centered Data Collection (CMS-10393)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/30/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2024
Responses	9,000	8,700
Time Burden (Hours)	2,250	2,175
Cost Burden (Dollars)	31,365	30,320

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Abstract: Information collection activities for the Beneficiary and Family Centered Information Collection include the following: Experience Survey: The population is comprised of Medicare beneficiaries who received support from a QIO with an appeal or complaint case. The sample will be stratified, analyzed, and reported by case type: • Appeal stratum – A simple random sample will be drawn of approximately 3 percent (9,000) of the annual universe (n=350,000). No sub-stratum oversampling will be used. This is expected to yield sufficient data to support quarterly analytic and evaluation reporting. • Complaint medical record review stratum - Given the relatively small annual volume (n=1,500), a census will be drawn in order to yield sufficient data for quarterly analytic and evaluation reporting. • Immediate advocacy stratum - A simple random sample will be drawn of approximately 30 percent (4,500) of the annual universe (n=15,000). No sub-stratum oversampling will be used. This is expected to yield sufficient data for quarterly analytic and evaluation reporting. Information collection will be conducted via telephone with paper surveys sent by mail upon request, and for those who do not respond by telephone. Data will be collected monthly with the annualized sample and burden hours allocated evenly across 12 months.

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Authorizing Statute(s): US Code: 42 USC 1320c Name of Law: Functions of Peer Review Organizations
  

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:
	88 FR 52166	08/07/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 73858	10/27/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393	Attachment B: Beneficiary Experience Survey

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ICR Summary 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	9,000	8,700	0	300	0	0
Annual Time Burden (Hours)	2,250	2,175	0	75	0	0
Annual Cost Burden (Dollars)	31,365	30,320	0	1,045	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total estimated burden for this request will increase by 75 hours (2,175 to 2,250) due to changes in the total universe volumes.

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Annual Cost to Federal Government: $3,100,802

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: 10/30/2023

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