CMS-381 Supporting Statement

SUPPORTING STATEMENT

FOR THE CMS-381

IDENTIFICATION OF EXTENSION UNITS OF MEDICARE APPROVED

OUTPATIENT PHYSICAL THERAPY/OUTPATIENT SPEECH PATHOLOGY (OPT/OSP)

PROVIDERS AND SUPPORTING REGULATIONS IN 42 CFR 485.701-485.729

A. BACKGROUND

This is a request for an extension for a currently approved collection for 0938-0273 (CMS-381, Identification of Extension Units of OPT/OSP Providers).

This form was developed to ensure that each extension unit of OPT/OSP providers at which they furnish services is reported by the providers to the State survey agencies. When an OPT/OSP provider furnishes services at locations other than the already Medicare-approved primary site, those locations/units may be considered to be a part of the OPT/OSP provider and subject to the same Medicare regulations as the primary site if the OPT/OSP submits evidence of supervision of these extension units.

B. JUSTIFICATION

1. Need and Legal Basis

Collection of this information is used in conjunction with 42 CFR 485.701 through 485.729 governing the operation of OPT/OSP facilities. The OPT/OSP provider uses the form to report to the State survey agency extension locations that it has added since the last survey by the State or date of last report.

2. Information Users

This form is used by the State survey agencies and by the CMS regional offices to identify and monitor extension locations to ensure their compliance with the Federal requirements for OPT/OSP facilities.

3. Improved Information Technology

This form does not request anything other than identifying data and providers are free to take advantage of any technological means for completion that are available.

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4. Duplication

This form does not duplicate existing data collection. No forms exist that are similar or that collect this data. This is the only mechanism to collect this data.

5. Small Business

This form will affect small business organizations, but the burden is very minimal and the data is not available from any other source.

6. Less Frequent Collection

Collection of this information coincides with the certification survey. If the information was collected less frequently than annually, it would result in surveys not being completed in projected timeframes and inefficient use of survey personnel.

7. Special Circumstances

No special circumstances exist for this information collection.

8. Federal Register and Outside Consultation

A 60-day Federal Register notice was published on June 6, 2008, attached.

CMS gives the public opportunities to comment on these information collection requirements (ICR) via the Paperwork Reduction Act of 1995. To date, we have not received any negative comments on these ICRs.

9. Payments or Gifts

There were no payments/gifts to respondents.

10. Confidentiality

CMS does not assure confidentiality.

11. Sensitive Questions

There are no sensitive questions on this form.

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12. Estimate of Burden (Hours and Wages)

It is estimated that there are 2960 respondents completing this form annually. The requested information should be readily available. The respondent only has to complete 3/4 of a 1-page form and it should not take any longer than 15 minutes to complete.

Estimate of Burden:

15 minutes per report

1 report per respondent filed annually

2960 respondents

740 hours of annual burden

It is estimated that this information collection requirements will cost the public $11,100 (740 hours x $15 per hour.

13. Capital Costs

There are no capital costs.

14. Federal Cost Estimates

The only cost to the Federal government is for printing the form. Printing costs for 2960 1-page forms is estimated at $473.60 (standard government calculation rate per printed page is $.16).

15. Burden Changes/Program Changes

There are no program or burden changes.

16. Publication and Tabulation Dates

There are no publication or tabulation dates.

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17. Expiration Date

CMS would like an exemption from displaying an expiration date; we would have to destroy potentially large quantities of forms to ensure the ones in use have the most recent expiration date.

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 this information collection.