Evaluation of Home Health Independence Demonstration: Home Health Agency Survey

Forms and Documents

Document Name	Status
Form CMS-10201 Evaluation of Home Health Independence Demonstration: Home Health Agency Survey Form and Instruction	New
Form CMS-10201 Evaluation fo Home Health Independence Demonstration: Survey of Home Health Agencies Form and Instruction	New
CMS-10201.Supporting Statement Part B (Statistical Methods).doc Supporting Statement B	2006-08-31
CMS-10201.Beacon Health Comments.pdf Supplementary Document	2006-08-31
CMS-10201 Response_to_Public_Comments.doc Supplementary Document	2006-08-31
CMS-10201.REVISED Emergency Justification.doc Supplementary Document	2006-08-31
CMS-10201.Supporting Statement and Instrument (final).pdf Supporting Statement A	2006-08-31

IC Document Collections

IC ID	Document Title	Status
45507	Evaluation of Home Health Independence Demonstration: Home Health Agency Survey Form and Instruction	New
45506	Evaluation fo Home Health Independence Demonstration: Survey of Home Health Agencies Form and Instruction	New

ICR Details

OMB Control No: 0938-1006	ICR Reference No: 200610-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Evaluation of Home Health Independence Demonstration: Home Health Agency Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/20/2006
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2006
	Date Received in OIRA: 10/03/2006
Terms of Clearance: Approved as an emergency collection. CMS will address any other public comments received prior to resubmission of the collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2007	6 Months From Approved
Responses	120	0	0
Time Burden (Hours)	60	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The survey is necessary to collect information about the Home Health Independence Demosntration mandated by Section 702 of the Medicare Modernization Act of 2003. The survey will be used to improve CMS's understanding of the application of the Medicare home health benefits eligibility criteria in the demonstration states. The survey will also contribute critical information to explain the relevance of the demonstration eligibility definition to the Medicare home health user population, and thereby assist CMS in future policymaking regarding home health eligibility.

Emergency Justfication: Please see the attached emergency justification document.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 703 Name of Law: Demonstration Project for Medical Adult Day Care Services
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 703 Name of Law: Demonstration Project for Medical Adult Day Care Services

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

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Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 42852	07/28/2006
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Evaluation fo Home Health Independence Demonstration: Survey of Home Health Agencies	CMS-10201	Survey of Home Health Agencies
Evaluation of Home Health Independence Demonstration: Home Health Agency Survey	CMS-10201	Survey of Home Health Agencies

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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	120	0	120	0	0	0
Annual Time Burden (Hours)	60	0	60	0	0	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: Please see the attached supporting statement. This a change in the statute.

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Annual Cost to Federal Government: $178

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]? 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: 09/05/2006

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