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	Modified
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation Form	Modified
CMS-10450 CAHPS for MIPS SS Part B (10-26-18)_clean.docx Supporting Statement B	2018-12-13
CMS-10450 - Supporting Statement A (version 4) CLEAN.docx Supporting Statement A	2018-12-13
Appendix G Technical References.docx Supplementary Document	2018-12-13

IC Document Collections

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

ICR Details

OMB Control No: 0938-1222	ICR Reference No: 201812-0938-014
Status: Active	Previous ICR Reference No: 201807-0938-014
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2019
	Date Received in OIRA: 12/13/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2022	36 Months From Approved	04/30/2020
Responses	39,336	0	132,783
Time Burden (Hours)	8,755	0	29,950
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is requesting clearance to implement a revised Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-based Incentive Payment System (MIPS). 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 the MIPS for eligible clinicians. The CAHPS for MIPS survey counts for one measure towards the MIPS quality performance category, and groups of two or more MIPS eligible clinicians can voluntarily elect to participate in the CAHPS for MIPS survey as one of their six required quality measures as finalized in the CY 2017 Quality Payment Program final rule. The use of a CAHPS survey (including the CAHPS for MIPS survey) would be counted as a high- weighted activity under the improvement activities performance category. We are requesting approval to use a revised, shorter version of the CAHPS for MIPS survey that will maintain or improve reliability while reducing beneficiary burden.

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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:
0938-AT31	Final or interim final rulemaking	83 FR 59452	11/23/2018

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 35704	07/27/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 59452	11/23/2018
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 Survey Vendor Application	CMS-10450, CMS-10450	Appendix F: Vendor Form ,   Appendix H: Vendor Attestation
CAHPS for MIPS Survey Beneficiary Participation	CMS-10450, CMS-10450	Attachment B: Mail Survey ,   Appendix E: CATI Script
CAHPS for MIPS Group Registration

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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	39,336	132,783	0	0	-93,447	0
Annual Time Burden (Hours)	8,755	29,950	0	0	-21,195	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: We assume that 282 groups will enroll in the MIPS for CAHPS survey based on the number of groups which elected to register during the CY 2018 registration period; a decrease of 179. Although the registration process remains unchanged from the CY 2018 Quality Payment Program final rule, after we reviewed the steps required for registration more thoroughly, we believe that the burden was less than we had originally estimated. Therefore, we have adjusted the estimated burden from 1.5 hours to 0.75 hours per respondent. We have also adjusted the number of groups electing to report on the CAHPS for MIPS survey as well as the average number of beneficiaries per group based on more recent data. We assume that 143 groups will elect to report on the CAHPS for MIPS survey, which is equal to the number of groups that have registered and have a sufficient beneficiary sample size to conduct the CAHPS for MIPS survey in the 2018 MIPS performance period; a decrease of 318 from the 461 groups currently approved by OMB. The survey will be administered to approximately 39,039 beneficiaries per year (143 groups x an average of 273 beneficiaries per group responding). This is a decrease of 93,268 from our currently approved 132,307 beneficiary estimate.

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Annual Cost to Federal Government: $2,120,324

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? 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: 12/13/2018

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