Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey

Forms and Documents

Document Name	Status
Form CMS-10615 Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey Form and Instruction	Modified
Justification for a Nonsubstantive Change [03-29-2016].doc Justification for No Material/Nonsubstantive Change	2016-03-29
CMS–10615 - HIP Beneficiaries Survey FR Notice.pdf Supplementary Document	2016-03-29
Justification for a Nonsubstantive Change [03-29-2016].doc Justification for No Material/Nonsubstantive Change	2016-03-29
Justification for a Nonsubstantive Change.doc Justification for No Material/Nonsubstantive Change	2016-03-25

IC Document Collections

IC ID	Document Title	Status
220696	Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1300	ICR Reference No: 201603-0938-017
Status: Historical Active	Previous ICR Reference No: 201603-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/18/2016
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/11/2016
	Date Received in OIRA: 03/25/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	09/30/2016	09/30/2016
Responses	36	0	36
Time Burden (Hours)	36	0	36
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected will be used to ensure that the survey instruments can be tested, revised, and finalized in enough time to allow: Indiana and public comment, submission and OMB approval of the main study package, survey data collection and analysis, and CMS deliberation regarding the waiver prior to its December 1, 2016 expiration date.

Emergency Justfication: See attached.

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Authorizing Statute(s): US Code: 42 USC 1315 Name of Law: Social Security Act
  

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

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
Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	CMS-10615, CMS-10615, CMS-10615, CMS-10615	Debriefing Script - Alternate Policy Survey Questions ,   Debriefing Script - Disenrolelee Lockout Survey ,   Debriefing Script - Enrollee Survey ,   Debriefing Script - New Enrollee Survey

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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	36	36	0	0	0	0
Annual Time Burden (Hours)	36	36	0	0	0	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:

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Annual Cost to Federal Government: $31,118

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? Yes

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: 03/25/2016

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