CMS-724 Supporting Statement

SUPPORTING STATEMENT FOR THE MEDICARE/MEDICAID

PSYCHIATRIC HOSPITAL SURVEY DATA

AND SUPPORTING REGULATIONS IN

42 CFR PARTS 482.60, 482.61 AND 482.62

A. BACKGROUND

The Medicare/Medicaid health Insurance Program is authorized by Title XVIII and XIX of the Social Security Act (the Act). This program provides reimbursement for the medical care of the aged, disabled persons and individuals whose income is insufficient to meet the cost of necessary medical services. Sections 1864, 1819(d), 1919(d), and 1102 of the Act require that facilities meet standards specified by the Secretary, DHHS, in order to be certified for Medicare/Medicaid reimbursement.

The form (CMS-724) is used to collect data that is not collected elsewhere

and assists CMS in program planning and evaluation of survey needs. We are

requesting and OMB extension for this currently approved collection (0938-

0378).

B. JUSTIFICATION

1. Need and Legal Basis

Statutory authority for this activity is found at Title XVIII, Section 1864 of the Act. This section recognizes psychiatric hospitals as Medicare providers and allows the Secretary to establish conditions of participation and to use State agencies under contract to assist in determining compliance with these conditions of participation. The special conditions of participation applicable to psychiatric hospitals are found in 42 CFR Parts 482.60, 482.61, and 482.62.

To determine compliance with conditions of participation, the Secretary has authorized States, through contracts, to conduct surveys of health care providers. Medicare’s approval or disapproval is based on a provider’s or supplier’s compliance or noncompliance with the health and safety requirements published in regulations.

The information collected on this form assists CMS in maintaining an accurate data base on providers participating in the Medicare psychiatric hospital program.

2. Information Users

The information collected on this form is used by CMS in evaluating the Medicare psychiatric hospital program. The form is also used for audit purposes; determining patient population and characteristics of the hospital; and survey term composition.

3. Improved Information Technology

Respondents are encouraged to take advantage of any technological resources available to them.

4. Duplication of Similar Information

This data collection form does not duplicate any other information collection and is specific to the psychiatric hospital program.

This survey form is the only standardized mechanism available for the surveyor/State agency to record the requested data.

5. Small Business

These forms do not impact small businesses.

6. Less Frequent Collection

Submission of the form depends on the frequency of surveys performed. The frequency of surveys for psychiatric hospitals depends on survey funding levels. The basic requirement is that this form is submitted for every survey conducted.

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 comments were received.

The CMS Form-724 was designed with the assistance of State agency staff, CMS regional office staff, and the CMS psychiatric consultants.

9. Payments/Gifts to Respondents

There were no payments/gifts to respondents.

10. Confidentiality

We make no pledges of confidentiality.

11. Sensitive Questions

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

12. Burden Estimates (Total Hours and Wages)

The completion of this form is estimated to take 30 minutes in total.

The data collection form has two parts; one part to be completed by the facility, and the other part to be completed by the survey team. The data requested from the facility is self-explanatory, should be kept in-house and should require no more than 15 minutes to fill out. The portion of the form to be completed by the survey team is basically a checklist and should require no more than 15 minutes to complete.

There are approximately 420 free-standing psychiatric hospitals in the universe; CMS surveys approximately 200 annually.

Number of providers in universe 420

Number of providers surveyed annually 200

Cost to complete form is based on

$40.00 per hour – based on 100 hours,

200 providers x ½ hour each = 100 hours $4,000

13. Capital Costs

There are no capital costs associated with this collection.

14. Cost to Federal Government

There are no additional costs to the Federal Government.

15. Change in Burden

There are no program or burden changes.

16. Publication and Tabulation Dates

There are no publication or tabulation dates.

17. Expiration Date

CMS would like to display the expiration date.

18. Certification Statement

There are no exceptions to the certification statements.

C. Collection of Information Employing Statistical Methods

Not applicable.