Medicare Health Outcomes Survey Field Test (CMS-10861)

Forms and Documents

Document Name	Status
Form CMS-10861 HOS Field Test Form and Instruction	New
CMS HOS - Supporting Statement A.docx Supporting Statement A	2023-10-27
CMS HOS - Supporting Statement B.docx Supporting Statement B	2023-10-27
CMS Response to Public Comments Received for CMS-10861.docx Supplementary Document	2023-10-27

IC Document Collections

IC ID	Document Title	Status
263064	HOS Field Test Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202310-0938-006
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Medicare Health Outcomes Survey Field Test (CMS-10861)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/27/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	6,800	0
Time Burden (Hours)	2,267	0
Cost Burden (Dollars)	0	0

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Abstract: The Centers for Medicare & Medicaid Services (CMS) has fielded the Medicare Health Outcomes Survey (HOS) annually since 1998. The HOS is a national survey of Medicare managed care plan enrollees that provides data that permit the calculation of both longitudinal and cross-sectional measures of plan performance that are publicly reported to assist Medicare beneficiaries in making enrollment decisions. This request is to conduct a field test to evaluate potential new survey items, alternatives to existing survey content, and the effects of a web-based survey administration mode on response patterns and measure scores. CMS’s goal is a refined and shorter HOS survey instrument with new and methodologically simpler cross-sectional and longitudinal measures, expanded measurement of physical functioning and mental health, and the addition of survey items that support CMS’s efforts to measure and address health equity.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Dug, Improvement, and Modernization Act
   US Code: 42 USC 422.162 Name of Law: Medicare Advantage Quality Rating System
  

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:
	88 FR 41404	06/23/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 73858	10/27/2023
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
HOS Field Test	CMS-10861, CMS-10861, CMS-10861	Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version A ,   Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version B ,   HOS Field Test Item Differences by Questionnaire

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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	6,800	0	0	0	6,800	0
Annual Time Burden (Hours)	2,267	0	0	0	2,267	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: $500,000

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

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]? 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: 10/27/2023

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