Supporting Statement
Emergency and Foreign Hospital Services--
Beneficiary Statement in Canadian/Mexican Travel Claims and Supporting Regulations in 42 CFR, Section 424.123
CMS-R-96
A. Background
Payment may be made for certain Part A inpatient hospital services and
Part B outpatient hospital services provided in a nonparticipating U.S. or foreign hospital when services are necessary to prevent the death or serious impairment of the health of the individual. In these situations, the threat to the life or health of the individual necessitates the use of the most accessible hospital available and equipped to furnish such services.
B. Justification:
1. Need and Legal Basis
Section 1866 of the Social Security Act states that any provider of services shall be Qualified to participate in the Medicare program and shall be eligible for payments under Medicare if it files an agreement with the Secretary to meet the conditions outlined in this section of the Act. Section 1814 (d) (1) of the Social Security Act, allows payment of Medicare benefits for a Medicare beneficiary to a nonparticipating hospital that does not have an agreement in effect with the Centers for Medicare and Medicaid Services. These payments can be made as such services were emergency services and CMS would be required to make the payment if the hospital had an agreement in effect and met the conditions of payment.
The emergency services furnished a beneficiary outside the U.S. are covered under Medicare if the foreign hospital meets the conditions for a domestic nonparticipating hospital in addition to one of the following: 1) if the emergency is considered to have occurred within the U.S. and the reason for departure for the U.S. was to obtain treatment; 2) if the emergency occurred in Canada while the beneficiary was traveling between Alaska and another State; 3) if the Canadian or Mexican hospital is closer, more accessible or adequately equipped to handle the illness or injury; or 4) services were rendered aboard a ship in an American port or on the same day the ship arrived or departed from that port.
2. Information Users
In Canadian travel claims, a statement is required from the beneficiary indicating the point of entry into Canada from the U.S.; the intended point of departure from Canada; the route being traveled at the time of the emergency; an explanation of any apparent deviation from the intended route; and an explanation of any non-routine stopover. The intermediary uses this information to determine if the travel was by the most direct route without unreasonable delay while the beneficiary was in route between Alaska and another State by the shortest practicable route, or while making a necessary stopover in connection with such travel.
3. Improved Information Technology
This request does not lend itself to automated processing.
4. Duplication
The data required are unique and not available from other sources.
5. Small Businesses
Small businesses are not involved in this information collection.
6. Less Frequent Collection
This information is collected only for Canadian travel claims as they occur.
7. Special Circumstances
The collection complies with the guidelines in 5 CFR 1320.6. There are no special circumstances.
8. Federal Register/Outside Consultation
The 60-day Federal Register notice was published on June 9, 2006, attached.
We did not conduct outside consultation since this is a non-controversial collection which has been in use for sometime.
9. Any Payment or Gift to Respondents
No gift to respondents.
10. Confidentiality
There is no assurance of confidentiality. The information collected will become part of the beneficiary’s claim for Medicare benefits.
11. Sensitive Questions
This collection does not solicit sensitive data.
12. Burden Estimate (Hours & Wages)
Average response time is estimated at 15 minutes. The time estimate for preparation of the CMS-R-96 is based upon the professional judgment of staff members at the Centers for Medicare and Medicaid Services.
There are approximately 1,100 claims filed annually at an average response time of 15 minutes. Therefore, we have calculated the burden as follows: 1,100 responses X 15 minutes per response = 275 burden hours.
Postage or mailing information to contractors:
(.39 X 1100 = $429)
13. Capital Costs
There are no capital costs.
14. Federal Cost Estimates
Postage and mailing information to beneficiary - $429
Handling and processing - $2750
Total yearly processing cost to the
Federal Government - $3179
15. Change in Burden
There are no changes to burden.
16. Publication Tabulation Dates
This data is not intended for publication
17. Display of Expiration Date
This collection does not lend itself to the displaying of an expiration date.
18. Certification Statement Exceptions
There are no exceptions associated with this collection
C. Collection of Information Employing Statistical Methods:
There are no statistical methods associated with this collection.
| File Type | application/msword |
| File Title | Supporting Statement |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2006-06-07 |
| File Created | 2006-05-30 |