Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)

Forms and Documents

Document Name	Status
Form CMS-10203 Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152 Form	Modified
Response to Comment _ HOS.doc Supplementary Document	2014-05-20
CMS-10203 - Supporting Statement B [rev 5-16-2014 by OSORA PRA].docx Supporting Statement B	2014-05-20
CMS-10203 - Supporting Statement A [rev 5-16-2014 by OSORA PRA].docx Supporting Statement A	2014-05-20

IC Document Collections

IC ID	Document Title	Status
203728	Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152 Form	Modified

ICR Details

OMB Control No: 0938-0701	ICR Reference No: 201405-0938-005
Status: Historical Active	Previous ICR Reference No: 201208-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2014
	Date Received in OIRA: 05/21/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	11/30/2015
Responses	1,737	0	666,120
Time Burden (Hours)	244,187	0	219,820
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services collects quality performance measures in order to hold the Medicare managed care industry accountable for the care being delivered, to enable quality improvement, and to provide quality information to Medicare beneficiaries in order to promote an informed choice. It is critical to CMS's mission that we collect and disseminate information that can be used to help beneficiaries choose among health plans, contribute to improved quality of care through identification of improvement opportunities, and assist CMS in carrying out its oversight and purchasing responsibilities.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   US Code: 42 USC 442, Subpart D Name of Law: null
  

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:
	79 FR 11434	02/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 28523	05/16/2014
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	CMS-10203, CMS-10203	Medicare Health Outcomes Survey (HOS 3.0) ,   Medicare Health Outcomes Survey-Modified (HOS-M)

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ICR Summary 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	1,737	666,120	0	0	-664,383	0
Annual Time Burden (Hours)	244,187	219,820	0	0	24,367	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: As demonstrated in the previously stated burden estimate calculations, changes to burden are the result of growth of Medicare Advantage program, including increases in enrollment, the number of contracts, and contract size, rather than changes to the HOS survey instrument proposed herein. On average, the burden to Medicare beneficiaries to complete a HOS or HOS-M survey has not changed; the survey burden remains at .33 hour. However, the number of MAOs required to report HOS Baseline has increased slightly, by 25 contracts, and the number of MAOs that remain in the MA program and are required to report HOS Follow-Up has increased significantly, by 122 contracts. As a result, the number of respondents has gone up by approximately 21,000 respondents for Baseline and 81,984 respondents for Follow-up, increasing HOS survey burden by approximately 33,985 hours. The burden to PACE was recalculated using a sample size based on actual enrollment. Although the number of participating PACE organizations has increased 50%, by 29 contracts, the revised total survey burden decreased by approximately 9,618 hours. Thus, the total survey burden for HOS and HOS-M combined increased approximately 24,367 hours. For a crosswalk of all survey instrument changes that includes new questions being added and current questions being removed or revised, see Attachment A.

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Annual Cost to Federal Government: $2,415,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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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: 05/21/2014

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