Supporting Statement for
CMS-29/30
Request for Certification as a Rural Health Clinic and Rural Health Clinic Survey Report Form and Supporting Regulations in 42 CFR 491.1-491.11
A. Background
The information collection requirements that are included with this request are for the currently approved collection Request for Certification as a Rural Health Clinic (CMS-29) (for which renewal is requested) and the Rural Health Clinic Survey Report Form (CMS-30) (which is now obsolete).
The Form CMS-29, Request for Certification as a Supplier of Rural Health Clinic (RHC) Services under the Medicare/Medicaid Program, is utilized as an application to be completed by suppliers of RHC services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services. It also promotes data reduction or introduction to and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices (ROs). Should any question arise regarding the structure of the organization, this information is readily available without going through the process of completing the form again.
The Form CMS-30 was an instrument that was used by the State survey agency to record data collected in order to determine RHC compliance with individual conditions of certification and to report it to the Federal government. The form was primarily a survey checklist/coding worksheet designed to facilitate data reduction (keypunching) and retrieval into ASPEN at the CMS ROs. The form included basic information on compliance (i.e., met, not met and explanatory statements) and did not require any descriptive information regarding the survey activity itself. CMS has the responsibility and authority for Medicare approval decisions which are based on RHC compliance with the conditions for certification. In the past, the information needed to make these decisions was available to CMS only through use of information abstracted from the survey checklists. This information is now captured directly within ASPEN; therefore, we no longer require the state agencies to complete this form. Additionally, the current version of the CMS-30 is outdated, since it does not reflect the current conditions for certification. The CMS-30 does not need to be renewed as a form for this package.
B. Justification
1. Need and Legal Basis
Collection of this information is authorized by 42 CFR 491.1 through 491.11 pursuant to sections 1864 and 1875 of the Social Security Act. Organizations rendering RHC services may participate as Part B Medicare/Medicaid suppliers. In order to determine compliance with the conditions for certification, the Secretary has authorized States through contracts to conduct surveys of health care providers and suppliers. For Medicare purposes, certification is based on the State agency's recording and reporting to CMS of a provider's or supplier's compliance or noncompliance with health and safety requirements.
The Request for Certification as a Supplier of RHC Services under the Medicare/Medicaid Program, form CMS-29, is an application form provided by the State agency to those persons who wish to operate Rural Health Clinics. It is completed and returned by the applicant and triggers the survey and certification process. After the State agency is sufficiently assured that this facility is operational, the State agency has an inspector/surveyor review the facility' s equipment and personnel and substantiates its compliance with State and local laws. The preliminary information provided on the Request for Certification form serves as the basis for the inspection. The request form also details the information which will be stored in the ASPEN and related survey and certification databases. The storage of the information allows for later retrieval for study reports and data collection.
The State agency is required to report its findings and make recommendations on supplier compliance or noncompliance to CMS. In order for the State to comply with this requirement the State agency must complete documentation in the ASPEN system, including a brief description of deficient practices that do not comply with the conditions for certification. The State agency surveyor is required to provide only very basic information concerning each area of deficiencies. The CMS 30 is no longer required to capture this survey information, and is being eliminated as a form.
2. Information Users
CMS uses the collected information to make certification decisions. When an RHC initially expresses an interest in participating in the Medicare program, it contacts the State agency which forwards the Request for Certification (CMS-29) to the supplier. The information on the completed form serves as a screener for the State agency to determine whether the RHC has the capabilities to participate in the Medicare program and whether a survey is appropriate. The basic identifying information from this form and the individual compliance codes from the survey form are incorporated into ASPEN and related survey and certification databases and serve as the information base for the creation of a record for future Federal certification and for monitoring activity.
3. Improved Information Technology
Survey findings are collected in the ASPEN electronic survey database; therefore, the CMS 30 has been eliminated.
4. Duplication of Similar Information
The CMS- 29 does not duplicate any information collection. The form addresses unique regulatory conditions of certification that RHCs must meet to participate in the Medicare program. State survey agencies receive Federal funds for conducting these reviews 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 RHC suppliers.
The CMS- 30 does not correspond to the current RHC conditions for certification, and the information is now captured in ASPEN. Accordingly, the CMS 30 will be deleted as a form.
5. Small Business
This collection does not affect small business.
6. Less Frequent Collection
Survey findings are collected and recorded in ASPEN based on the frequency of surveys specified in regulations and the availability of survey funds. It is a basic contract requirement that State surveyors transmit their compliance findings for each survey they conduct. If this information would be collected less frequently it would prevent certification of needed RHCs and deny access to primary care services in rural health areas.
7. Special Circumstances for Information Collection
There are no special circumstances associated with this collection. These requirements comply with all general information collection guidelines in 5 CFR 1320.6.
8. Federal Register and Outside Consultation
A 60-day Federal Register notice was published on 9/12/2008, attached. We have not sought outside consultations via the paperwork reduction act of 1995 in reference to this form since the last OMB approval. It is basically a checklist or coding worksheet that lists conditions and standards which State surveyors evaluate during RHC supplier compliance surveys. It represents, perhaps, the simplest method available for reporting the information to CMS on supplier compliance with the individual regulatory requirements for participation in Medicare.
9. Payments or Gifts
There are no payments of gifts associated with this collection.
10. Confidentiality
We do not pledge confidentially
11. Sensitive Questions
There are no questions of a sensitive nature associated with this form.
12. Estimate of Burden
There are 3,827 Rural Health Clinics in the universe; we survey approximately 20 percent annually.
Certification Form
Based on past usage of this form and the general nature of the questions, we estimate that it takes approximately 15 minutes to complete this form. Total burden for the certification form is 192 hours. 766 suppliers times 15 minutes per form, equals 11,490 minutes or 192 hours.
The total burden for CMS-29 is 192 hours. We estimate that the information collection requirements will cost the public 4,800 (192 hours times $25.00 per hour)
13. Annualized Cost of Burden
There are no annualized costs associated with this collection.
14. Federal Cost Estimates
Total Federal Cost - $5,700.00
Number of suppliers in universe 3,827
Number of suppliers surveyed annually 766
Contracting costs to complete forms $4,800*
Printing of forms CMS-29 and Distribution:
CMS-29 $900.00
* The amount for completion of forms was calculated using an average hourly salary of $25.00/hour for state inspectors, an average of 1.75 hours for surveyors completion of both forms, and a supplier base of 766.
All costs associated with completion of this form are incurred by the Federal government.
15. Burden Changes/Program changes
The burden decrease is due to the removal of the CMS-30 from this package. States are no longer required to complete the CMS-30.
16. Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. OMB Expiration Date
CMS does not object to displaying the OMB expiration date.
18. Certification Statement
There are no exceptions to the certification statement.
C. Collection of Information Employing Statistical Methods
There are no statistical methods employed in this information collection.
| File Type | application/msword |
| File Title | Supporting Statement for |
| Author | CMS |
| Last Modified By | ht80 |
| File Modified | 2008-12-12 |
| File Created | 2008-12-12 |