CMS-417 Supporting Statement

SUPPORTING STATEMENT

FOR THE

HOSPICE REQUEST FOR CERTIFICATION (CMS-417)

AND SUPPORTING REGULATIONS

A. BACKGROUND

This is a request for a 3 year extension of approval for the CMS-417, the Hospice Request for Certification in the Medicare Program which is currently approved under OMB # 0938-0313.

The certification form is an identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program. If a provider meets these preliminary requirements, a survey is scheduled to determine if the provider complies with the conditions of participation required by the Medicare program. The data on this form serve as a basis for the inspection. The facility is only required to complete certain items on the certification forms as indicated by the instructions included with the form. These items are explained below.

B. JUSTIFICATION

1. Need and Legal Basis

This activity is authorized by section 122 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (Public Law 97-248) and section 1861(dd) of the Social Security Act, which allow hospice entities to participate as Medicare providers of services if the entities meet regulatory conditions of participation. For Medicare purposes, certification is based on the State survey agency's reporting of the provider's compliance or noncompliance with the health and safety requirements published in regulations. To determine compliance with the requirements, the Secretary has authorized States through contracts to conduct surveys of these providers.

This certification form is used in the initial stages of the survey process to gather and record minimum identification information into the Online Survey, Certification, and Reporting (OSCAR) System in the State and at the central and regional offices of the Centers for Medicare and Medicaid Services (CMS).

Section 1861(dd) of the Social Security Act (the Act) defines Hospice Care and Hospice Program with respect to The Medicare Hospice Benefit. 42 CFR 418 sets forth the Health and Safety Conditions of Participation (CoPs) that all Hospices must meet to participate in Medicare. State survey agencies are used by CMS to determine if the CoPs are met.

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2. Information Users

The information from this form will be used by CMS in making initial certification and subsequent recertification decisions. Initially, when a hospice expresses an interest in participating in the Medicare program, it contacts the State agency which forwards the Request for Certification (CMS-417) to the applicant. The information on the form serves as a screen for the State agency to determine if the hospice has the basic capabilities to participate in the Medicare program, and whether a survey is appropriate. At the time of the recertification, the form is also completed so that the necessary identification data may be revised in the event that there have been changes. The identifying information from this form is coded into the OSCAR system and serves as the information base for the creation of a record for future Federal certification and monitoring activity.

3. Improved Information Technology

The certification form lists minimum criteria that must be met in order to be approved for Medicare participation. The standardized format and simple checkbox method provide for consistent reporting by State survey agencies. Recording this information would be no easier for State surveyors using direct access equipment.

4. Duplication of Similar Information

This certification form does not duplicate any information collection. The form addresses specific requirements for certification. State survey agencies conduct these reviews with Federal funds under contract with CMS. This form is a basic deliverable under these contracts and is the only one of its kind collected by CMS for hospices.

5. Small Business

This form is completed by small businesses, but is a necessary data collection, with minimal burden imposed.

6. Less Frequent Collection

Submission of the certification form is based on the frequency of surveys. These surveys, in turn, depend on the frequency specifications of regulations and the availability of survey funds.

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7. Special Circumstances

There are no special circumstances.

8. Federal Register Notice/Outside Consultation

A 60-day Federal Register notice was published on 5/4/2007. No additional outside consultation was made as this is not a new collection and no changes have been made since the last submission.

9. Payment Gift to Respondent

There are no payment/gifts to respondents.

10. Confidentiality

We do not pledge confidentiality.

11. Sensitive Questions

There are no questions of a sensitive nature on the form.

12. Burden Estimate (Total Hrs. & Wage)

Initially, this form is completed by the facility expressing an interest in participating in the Medicare program. (Thereafter, it is completed by the State agency surveyor.) We estimate, based on the simplicity of the form and past usage, that it takes approximately 15 minutes to complete.

2286 Hospices completing the form

x .25 Minutes to complete form

571.50 Hours of burden for completion of form

Public Cost

The financial cost to the public rests solely with the time/salary element of hospice employees that complete the request for certification.

572 hours x $40.00 (professional hourly wage for Federal calculations) = $22,880.

13. Capital Costs

There are no capital costs.

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14. Cost to Federal Government

Federal cost involvement with the request for eligibility form relates only to printing costs. The form (CMS-417) is a one-page form with three carbon duplicate pages and a one-page instruction sheet.

Total pages = 5

Total costs = 5 pages per form x 5,160 forms =25,800 pages x $.20 per page (standard government calculation rate per printed page) = $5,160.

15. Program/Burden Changes

There are no program or burden changes.

16. Publication and Tabulation Dates

There are no publication and tabulation dates.

17. Expiration Date

CMS would like an exemption to displaying the expiration date. The form is used on a continuing basis and it would uneconomical to have to revise and reprint it every three years and to destroy expired forms.

18. Certification Statement

There are no exceptions to the certification statement.

C. Collections of Information Employing Statistical Methods

There are no statistical methods employed in the information collected.