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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1440
ICR Reference No:
202211-0938-013
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMC-CPC
Title:
Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
03/14/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/29/2022
Terms of Clearance:
Within 90 days of approval of this ICR, CMS is required to survey its other ICR packages and submit non-substantial change requests to revise its new racial question. This revision will ensure appropriate and tested alphabetization of racial categories with nested sub-categories of race rather than alphabetization of all sub-categories together. Also "other" sub-categories should be at the bottom of the sub-category list such as "other Asians." CMS is encouraged to follow-up if it needs additional guidance.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2026
36 Months From Approved
Responses
470
0
0
Time Burden (Hours)
114
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
CMS’ primary objective for the interviews is to identify the drivers of nonresponse to the race and ethnicity questions. Specifically, we aim to solicit detail on whether and what concerns drove individuals’ nonresponse to these items, including (but not limited to) (a) concerns about confidentiality of their data, (b) concerns about how their race and ethnicity data would be used, including concerns about whether disclosing such information could in any way affect eligibility for Medicare benefits (which it would not), or (c) concerns about response options (e.g. missing response options for race or ethnicity groups in which they may identify). We also intend to explore whether it is possible to amend the race and ethnicity elements on Part C/D enrollment form to address any of those concerns, and if so, how. Additionally, we plan to ask whether there are other – beyond the Part C/D enrollment form – vehicles for collecting race and ethnicity information that would be more acceptable to non-responders, and if so, what those are.
Authorizing Statute(s):
PL:
Pub.L. 105 - 33 Sec 4001
Name of Law: Balanced Budget Act of 199
PL:
Pub.L. 108 - 173 Sec. 101
Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
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:
87 FR 51675
08/24/2022
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 72485
11/25/2022
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Interview Guide
CMS-10816, CMS-10816
Informed Consent
,
Cognitive Interview Protocol
Invitation & Screening
CMS-10816, CMS-10816
Recruitment Script
,
Eligibility Screener Questionnaire
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
470
0
0
0
470
0
Annual Time Burden (Hours)
114
0
0
0
114
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:
Annual Cost to Federal Government:
$122,904
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.
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
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
Common Form ICR:
No
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:
11/29/2022
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