DOCUMENTATION FOR THE GENERIC CLEARANCE

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Request for Approval under the “Generic Clearance for Improving Customer Experience: OMB Circular A-11, Section 280 Implementation” 
(OMB Control Number:0982-1382 GenIC#11)

TITLE OF INFORMATION COLLECTION:  - Notice Testing: CMS Notice of Change of Status (CMS10868)

PURPOSE OF COLLECTION:  
What are you hoping to learn / improve? How do you plan to use what you learn? Are there artifacts (user personas, journey maps, digital roadmaps, summary of customer insights to inform service improvements, performance dashboards) the data from this collection will feed?

The data from this collection will be used to improve the language and layout of a notice that informs people with Medicare that their hospital status changed from inpatient to outpatient receiving observation services, how this status change impacts how Medicare covers the current stay as well as post hospital-stay skilled nursing facility coverage, and their rights to appeal the decision. The goal is to ensure that the notice is easy for recipients to understand that their status has changed, and what steps they can take as a result. 

TYPE OF ACTIVITY: (Check one)

[  X ] Customer Research (Interview, Focus Groups, Surveys)	
[   ] Customer Feedback Survey 
[   ] Usability Testing of Products or Services 

ACTIVITY DETAILS

    1. If this is a survey, will the results of this survey be reported to Touchpoints as part of quarterly reporting obligations specified in OMB Circular A-11 Section 280?
[  ] Yes
[  ] No
[ X ] Not a survey

    2. How will you collect the information? (Check all that apply)
[ X ] Web-based or other forms of Social Media 
[  ] Telephone	
[ X ] In-person 
[  ] Mail 
[  ] Other, Explain

    3. Who will you collect the information from?
Explain who will be interviewed and why the group is appropriate for the Federal program / service to connect with. Please provide a description of how you plan to identify your potential group of respondents and if only a sample will be solicited for feedback, how you will select them(e.g., anyone who provided an email address to a call center rep, a representative sample of Veterans who received outpatient services in May 2019, do you have a list of customers to reach out to (e.g., a CRM database that has the contact information, intercept interviews at a particular field office?) 

Individuals who currently have Original Medicare will be recruited for this research. Individuals with just Part A or Part A and B are the types of individuals who would receive the notice being tested, if the hospital where they are receiving care changes their inpatient status to outpatient receiving observation. 

Participants will be recruited using professional recruiters who will reach out to people in their sample panels who are over the age of 65. Those who are in that age group will be asked whether they have Original Medicare or a Medicare Advantage plan and whether they have Medicare Part A only or Parts A and B. 

    4. How will you ask a respondent to provide this information? 
(e.g., after an application is submitted online, the final screen will present the opportunity to provide feedback by presenting a link to a feedback form / an actual feedback form)

We will conduct one-on-one semi-structured in-depth interviews with participants and will document their feedback.

    5. What will the activity look like?
Describe the information collection activity – e.g. what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group? If a survey, describe the overall survey layout/length/other details? If User Testing, what actions will you observe / how will you have respondents interact with a product you need feedback on? 

When a person agrees to participate, the recruiter will schedule their interview and provide them with information regarding the time and location (physical or online) of their session. Those who will be participating online will be provided with the link to the testing environment, and will undergo a technical check to ensure that they are able to fully participate prior to their session. Each interview will be facilitated by a professional moderator. The sessions will be streamed and recorded so that a notetaker and other research observers may observe. The moderator will guide the conversation, giving the participants an opportunity to read through the notice while indicating areas of confusion and importance. Next, the moderator will ask questions based on the items that the participant identified during their review of the notice. Next, the moderator will ask questions to prompt discussion about each section of the notice. The notetaker and observers will be remote (not in the same room as the sessions). Note taker will take notes using appropriate software, observers will watch the sessions. 

    6. Please provide your question list.
Paste here the questions or prompts presented to participants in your activity. If you have an interview / facilitator guide, that can be attached to the submission and referenced here. 

See the interview guide.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

    7. When will the activity happen?
Describe the time frame or number of events that will occur (e.g., We will conduct focus groups on May 13,14,15, We plan to conduct customer intercept interviews over the course of the Summer at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10th, or “This survey will remain on our website in alignment with the timing of the overall clearance.”)

This ICR is intended to cover testing to occur between July and October 2024. The testing will be conducted in up to two phases: Phase 1 in July will allow for research-driven improvements to be made and tested in Phase 2 in October if needed.

    8. Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?  
[ x ] Yes [  ] No  
If Yes, describe:

$75 Visa or other cash equivalent gift card


BURDEN HOURS 

Category of Respondent 
No. of Respondents
Participation Time
Burden
Hours
Medicare beneficiaries with Original Medicare (type 1)
24
60 minutes
24
Totals
24
24 hours
24

CERTIFICATION:

I certify the following to be true: 
    1. The collections are voluntary;
    2. The collections are low-burden for respondents (based on considerations of total burden hours or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;
    3. The collections are non-controversial;
    4. Any collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the near future;
    5. Personally identifiable information (PII) is collected only to the extent necessary and is not retained;
    6. Information gathered is intended to be used for general service improvement and program management purposes
    7. The agency will follow the procedures specified in OMB Circular A-11 Section 280 for the required quarterly reporting to OMB of trust data and experience driver data from surveys. 
    8. Outside of the quarterly reporting mentioned in the bullet immediately above, if the agency intends to release journey maps, user personas, reports, or other data-related summaries stemming from this collection, the agency must include appropriate caveats around those summaries, noting that conclusions should not be generalized beyond the sample, considering the sample size and response rates. The agency must submit the data summary itself (e.g., the report) and the caveat language mentioned above to OMB before it releases them outside the agency. OMB will engage in a passback process with the agency.  

Name and email address of person who developed this survey/focus group/interview: 
      
Name: Kymeiria Ingram-McNeil ____________________

Email address: [email protected]___________

All instruments used to collect information must include:
OMB Control No. 0982-1382
Expiration Date: XX/XX/XXXX
HELP SHEET
(OMB Control Number: XXXX-XXXX)

TITLE OF INFORMATION COLLECTION:  Provide the name of the collection that is the subject of the request. (e.g.  Comment card for soliciting feedback on xxxx)

PURPOSE:  Provide a brief description of the purpose of this collection and how it will be used.  If this is part of a larger study or effort, please include this in your explanation.

TYPE OF COLLECTION: Check one box.  If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION:  Please read the certification carefully.  If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information:  Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

BURDEN HOURS:
Category of Respondents:  Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government.  Only one type of respondent can be selected per row. 
No. of Respondents:  Provide an estimate of the Number of respondents.
Participation Time:  Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)
Burden:  Provide the Annual burden hours:  Multiply the Number of responses and the participation time and divide by 60.