Medicare Health Outcomes Survey (HOS) (CMS-10203)

Forms and Documents

Document Name	Status
Form CMS-10203 Medicare Health Outcomes Survey (HOS) Form	Modified
CMS-10203 Supporting Statement A.docx Supporting Statement A	2021-05-07
CMS-10203 Supporting Statement B.docx Supporting Statement B	2021-04-29
Attachment A. Crosswalk of Changes.pdf Supplementary Document	2021-04-29
Attachment G. CMS Response to Public Comments Received for CMS-10203.docx Supplementary Document	2021-04-29

IC Document Collections

IC ID	Document Title	Status
203728	Medicare Health Outcomes Survey (HOS) Form	Modified

ICR Details

OMB Control No: 0938-0701	ICR Reference No: 202104-0938-016
Status: Received in OIRA	Previous ICR Reference No: 201709-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Health Outcomes Survey (HOS) (CMS-10203)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/10/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2021
Responses	629,280	1,485
Time Burden (Hours)	201,370	183,115
Cost Burden (Dollars)	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
  

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:
	86 FR 8362	02/05/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 24624	05/07/2021
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)	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 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	629,280	1,485	0	627,795	0	0
Annual Time Burden (Hours)	201,370	183,115	0	18,255	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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 burden adjustments on MAOs and PACE plans are due to changes in the number of MAOs required to administer the HOS and the number of PACE plans required to administer the HOS-M. The total number of MAOs required to report HOS Baseline and Follow-Up increased by 47 and 68 MAOs, respectively, since the previous OMB submission. The increase in the number of contracts required to report HOS Baseline and Follow-Up in 2020 was largely due to changes in the number of MA contracts. The burden adjustments on PACE plans are a result of changes in the number of PACE plans required to report HOS-M. The number of PACE plans required to administer the HOS-M increased by 17 since the last OMB package. There has been tremendous growth in PACE during the last decade and the program continues to grow.

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Annual Cost to Federal Government: $3,000,000

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

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: 05/10/2021

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