An Important Message from Medicare

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
8303	An Important Message from Medicare Form	Migrated

ICR Details

OMB Control No: 0938-0692	ICR Reference No: 199607-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: An Important Message from Medicare
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/11/1996
	Date Received in OIRA: 07/19/1996
Terms of Clearance: Approved for use through 10/98 under the conditions that: 1) HCFA amend the disclosure to clarify the nature of decisions that must be agreed upon or disagreed upon between physicians, hospitals, and PROs. For example, in the second bullet under the last section of the first page, the phrase "If the hospital or your doctor agree" should be amended to read "If the hospital and your doctor agree that you can leave the hospital." All other vague references to agreements and disagreements on both pages of the disclosure should be clarified in a similar fashion. OMB staff offer assistance in making these amendments. The amended dis- closure statement must be shared with OMB and receive approval before it is disseminated in the field; and 2) the next submission for OMB review evaluates the effectiveness of this disclosure statement in educating beneficiaries and evaluates alternatives for disclosure, including other flexibile options under consideration by the M-TAG. For example, video/visual disclosures may be more effective for certain beneficiaries than this hard copy version.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/1998	10/31/1998
Responses	11,000,000	0	0
Time Burden (Hours)	183,333	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Hospitals participating in the Medicare program have agreed to distribute "An Important Message from Medicare" to beneficiaries during each admission. Receiving this information will provide the beneficiary with some ability to participate and/or initiate discussions concerning decisions affecting Medicare coverage or payment and about his or her appeal rights in response to any hospital's notice to the effect that Medicare will no longer cover continued care in the hospital.

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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
An Important Message from Medicare	HCFA-R-193

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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	11,000,000	0	0	11,000,000	0	0
Annual Time Burden (Hours)	183,333	0	0	183,333	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: 07/19/1996

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