Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

Forms and Documents

Document Name	Status
Form CMS-10450 CAHPS for MIPS Survey Vendor Application Form and Instruction	Unchanged
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation Form	Unchanged
CMS-10450 response to comments CAHPS MIPS 7_15_21.docx Supplementary Document	2021-07-21
CMS-10450 Supporting Statement B (12-22-20).docx Supporting Statement B	2021-02-26
CMS-10450 - Supporting Statement A_ 1-22-21.docx Supporting Statement A	2021-07-21
Appendix G Technical References.docx Supplementary Document	2018-12-13

IC Document Collections

IC ID	Document Title	Status
227777	CAHPS for MIPS Group Registration	Unchanged
227776	CAHPS for MIPS Survey Vendor Application Form and Instruction	Unchanged
206234	CAHPS for MIPS Survey Beneficiary Participation Form	Unchanged

ICR Details

OMB Control No: 0938-1222	ICR Reference No: 202107-0938-012
Status: Received in OIRA	Previous ICR Reference No: 202102-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/21/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2021
Responses	30,249	30,249
Time Burden (Hours)	6,902	6,902
Cost Burden (Dollars)	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS. The CAHPS survey information is used for quality reporting to collect data on fee-for-service Medicare beneficiaries’ experiences of care with eligible clinicians participating in MIPS, the Physician Compare website, and annual statistical reports describing MIPS data for all MIPS eligible clinicians.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015
   PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015

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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 23384	05/03/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 38486	07/21/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
CAHPS for MIPS Group Registration
CAHPS for MIPS Survey Beneficiary Participation	CMS-10450, CMS-10450	Mail Survey ,   CAHPS for MIPS CATI Script
CAHPS for MIPS Survey Vendor Application	CMS-10450, CMS-10450	Appendix F: Vendor Form ,   Appendix H: Vendor Attestation

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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	30,249	30,249	0	0	0	0
Annual Time Burden (Hours)	6,902	6,902	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: $2,177,573

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.     Yes

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.     Yes

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? Yes

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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: 07/21/2021

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