Medicare Disproportionate Share Adjustment Procedures and Criteria and Supporting Regulations in 42 CFR 412.106

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-R-194 Supporting Statement.doc	Supporting Statement A	Uploaded 2009-08-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43662	Medicare Disproportionate Share Adjustment Procedures and Criteria and Supporting Regulations in 42 CFR 412.106		Modified

ICR Details

OMB Control No: 0938-0691	ICR Reference No: 200908-0938-006
Status: Historical Active	Previous ICR Reference No: 200606-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Disproportionate Share Adjustment Procedures and Criteria and Supporting Regulations in 42 CFR 412.106
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/05/2009
	Date Received in OIRA: 08/19/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved	10/31/2009
Responses	800	0	100
Time Burden (Hours)	400	0	100
Cost Burden (Dollars)	0	0	0

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Abstract: A hospital's disproportionate share adjustment is determined by its fiscal intermediary (FI) using a combination of Medicare Part A and SSI data provided by CMS, and Medicare date calculated from the hospital's cost report. The data provided through these calculations are then compared to the qualifying criteria located in 42 CFR 412.106 to determine the final adjustment. If these calculations, based on the Federal fiscal year, do not allow the hospital to qualify for a disproportionate share adjustment, the hospital may request that they be performed using its cost reporting period.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AN57	Final or interim final rulemaking	70 FR 47278	08/12/2005

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 22932	05/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 38207	07/31/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Disproportionate Share Adjustment Procedures and Criteria and Supporting Regulations in 42 CFR 412.106

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ICR Summary of Burden

table that charts list 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	800	100	0	0	700	0
Annual Time Burden (Hours)	400	100	0	0	300	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: The increase in burden is due to an estimated increase in the number of requests for recalculation and also the estimated increase in the number of requests for MedPAR data that resulted from the FY 2006 Inpatient Prospective Payment System Rule. Because of this rule, CMS no longer requires that a hospital have a properly pending appeal before the PRRB relating to the hospital’s DSH patient percentage in order to request its MedPAR data associated with calculation of its “Medicare fraction” or “SSI ratio” beginning with cost reporting periods that include December 8, 2004 (70 Fed. Reg. 47439). Consequently, CMS also no longer charges for data associated with these time periods.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

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)? No

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: 08/19/2009

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