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OMB Control No: 0938-1177	ICR Reference No: 201509-0938-012
Status: Historical Active	Previous ICR Reference No: 201305-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 19423
Title: Medicare Beneficiary and Family-Centered Satisfaction Survey
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: 09/26/2016
	Date Received in OIRA: 09/25/2015
Terms of Clearance: Pursuant to 5 CFR 1320, on the condition that all required data collection instruments associated with the information collection request display OMB control number and current expiration date, the information collection is approved for three (3) years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	16,010	0	68,000
Time Burden (Hours)	4,003	0	17,000
Cost Burden (Dollars)	20,013	0	85,000

Abstract: The data collection methodology used for the Beneficiary Satisfaction will be conducted primarily via mail. A mail-based methodology will achieve the goals of being efficient, effective, and minimally burdensome for beneficiary respondents. A mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Using the 3-step mail approach described above, we anticipate that data collection would occur over an 8 to 10 weeks. This is to say, if the first survey mailing were dropped on January 1, we would anticipate completing data collection at the end of February or early March. Data would then be cleaned, scores would be generated, and data would be delivered to CMS. As previously described, we anticipate that a mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we would recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Through the pilot test, we will determine the response rate that can be achieved using this approach. If it is deemed necessary, additional mailout reminders can be added to the protocol, or a telephone non-response step can be added to the protocol. Using the 3-step mail approach described above, we anticipate that data collection would occur over an 8 to 10 weeks.

Authorizing Statute(s): US Code: 42 USC 1320c Name of Law: Functions of Peer Review Organizations

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 43091	07/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57821	09/25/2015
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393, CMS-10393, CMS-10393, CMS-10393	, , ,

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	16,010	68,000	-51,990
Annual Time Burden (Hours)	4,003	17,000	-12,997
Annual Cost Burden (Dollars)	20,013	85,000	-64,987

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There was an error in the numbers. Previous numbers reflected 3 year numbers instead of annual numbers in the "ICR Summary of Burden"

Annual Cost to Federal Government: $997,000

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

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]? 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? Uncollected

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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