MEDICAID PROVIDERS TAXES AND DONATIONS PROGRAMS APPLICATION

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
114050	MEDICAID PROVIDERS TAXES AND DONATIONS PROGRAMS APPLICATION Form	Migrated

ICR Details

OMB Control No: 0938-0595	ICR Reference No: 199110-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: MEDICAID PROVIDERS TAXES AND DONATIONS PROGRAMS APPLICATION
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 without change	Conclusion Date: 10/31/1991
	Date Received in OIRA: 10/29/1991
Terms of Clearance: This information collection is approved through 2-92 under the following conditions: 1) On Attachment I, after number 6, add a question to determine whether the costs of the tax are included in the base year costs for payment rate calcuation, for provider's paid on a prospective basis. 2) The questions in Attachment I, 9.(b), and Attachment II, 7.(b) must be clarified. Possible wording might include, "Return to questions 1 through 8, and respond according to the conditions outlined in your proposed tax/donation program." 3) Under the Supplementary Information Section, label the existing question subset A, and add a subset B question which will read, "Please provide data on Medicaid utilization and/or Medicaid revenues as a percentage of total utilization and/or total revenues for institutional providers, i.e. hospitals, nursing homes and ICF MR's. Also provide disproportionate share adjustment amounts by hospital for each hospital eligible to receive such adjustments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/1992	02/28/1992
Responses	50	0	0
Time Burden (Hours)	4,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: THIS APPLICATION WILL BE USED BY STATES SEEKING A DELAYED EFFECTIVE DA FOR THE PROVISIONS CONTAINED IN INTERIM FINAL REGULATIONS, MB-022-IFC, TO REVISE ITS TAX LAWS OR PROVIDER DONATION ARRANGEMENTS TO BE CONSISTENT WITH THIS RULE. THE STATES MUST COMPLETE AN APPLICATION TO BE SELECTED IN THIS PROGRAM.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
MEDICAID PROVIDERS TAXES AND DONATIONS PROGRAMS APPLICATION	HCFA-840

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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	50	0	0	50	0	0
Annual Time Burden (Hours)	4,000	0	0	4,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

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: $0

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

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 10/29/1991

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