Montana Health and Economic Livelihood Partnership (HELP) Federal Evaluation (CMS-10635)

OMB 0938-1332

This information collection request is for conducting a customer satisfaction survey, focus groups, and informational interviews as part of site visits to Billings, Helena, Blackfeet Indian Reservation, and Havre in Montana, relating to the Montana Health and Economic Livelihood Partnership (HELP) Program Demonstration. Respondents will include beneficiaries enrolled and disenrolled in the HELP Medicaid Demonstration as well as stakeholders and consumer advocates. The data collection effort is part of a larger federal assessment of the HELP Demonstration that will inform the continued policy decision making regarding the HELP Demonstration (Section 1115 Demonstration) as well as other similar Medicaid expansion policies.

The latest form for Montana Health and Economic Livelihood Partnership (HELP) Federal Evaluation (CMS-10635) expires 2020-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10625 Informational Interviews Form and Instruction
Form CMS-10625 Beneficiary Focus Groups Form and Instruction
Form CMS-10635 Beneficiary Surveys Form
CMS-10635 - Supporting Statement A (OMB Passback 1)_rev_clean.docx Supporting Statement A
CMS-10635 - Supporting Statement B (OMB Passback 1)_rev_clean.docx Supporting Statement B
Informational Interviews Form and Instruction
Beneficiary Focus Groups Form and Instruction
Beneficiary Surveys Form

All Historical Document Collections

201705-0938-008

Approved with change

New collection (Request for a new OMB Control Number)

2017-05-16

OMB Details

Beneficiary Surveys

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10635	Disenrollee and Lockout Beneficiary Survey (Screen Shots)	Fillable Fileable	Form
Form CMS-10635	Beneficiary Survey: Disenrollees (Spanish, paper)	Paper Only	Form
Form CMS-10635	Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots)	Fillable Fileable	Form
Form CMS-10635	Beneficiary Survey: Enrollees (Spanish, paper)	Paper Only	Form
Form CMS-10635	Beneficiary Survey: Enrollees (paper)	Paper Only	Form
Form CMS-10635	Enrollee Beneficiary Survey (Screen Shots)	Fillable Fileable	Form
Form CMS-10635	Beneficiary Survey: Disenrollees (paper)	Paper Only	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.