Home Health Advance Beneficiary Notices and Supporting Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e)

Forms and Documents

Document Name	Status
Form CMS-R-296 Home Health Advance Beneficiary Notices and Supporting Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e) Form	Modified
Crosswalk Document for Changes to HHABN422.doc Supplementary Document	2009-08-07
CMS-R-296 track changesHHABN.doc Supplementary Document	2009-08-07
HHABN Supporting Stmt FINAL.doc Supporting Statement A	2009-08-07

IC Document Collections

IC ID	Document Title	Status
43668	Home Health Advance Beneficiary Notices and Supporting Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e) Form	Modified

ICR Details

OMB Control No: 0938-0781	ICR Reference No: 200908-0938-007
Status: Historical Active	Previous ICR Reference No: 200606-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Home Health Advance Beneficiary Notices and Supporting Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e)
Type of Information Collection: Revision 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:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved	10/31/2009
Responses	12,349,787	0	10,351,703
Time Burden (Hours)	1,028,737	0	780,918
Cost Burden (Dollars)	0	0	0

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Abstract: Home health agencies (HHAs) are required to provide written notice to Medicare beneficiaries under various circumstances involving the initiation, reduction, or termination of services. The HHABN underwent format modifications so that the previously approved HHABN, which until that time served solely as a notification of liability notice, could also be used for beneficiary notification of changes of care consistent with HHA conditions of participation (COPs). The notice is designed to ensure that beneficiaries receive complete and useful information regarding potential financial liability or any changes made to their plan of care (POC) to enable them to make informed consumer decisions. The notice must provide clear and accurate information about the specified services and, when applicable, the cost of services when Medicare denial of payment is expected by the HHA.

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Authorizing Statute(s): US Code: 42 USC 1395(bbb) Name of Law: HHA Conditions of Participation
   Statute at Large: 18 Stat. 1879 Name of Statute: null
   Statute at Large: 18 Stat. 1834 Name of Statute: null
   Statute at Large: 18 Stat. 1842 Name of Statute: null
   Statute at Large: 18 Stat. 1891 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

IC Title	Form No.	Form Name
Home Health Advance Beneficiary Notices and Supporting Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e)	CMS-R-296, CMS-R-296-SP	Home Health Advance Beneficiary Notice (HHABN) ,   Aviso Anticipado al Beneficiario de los Servicios de Salud en el Hogar

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ICR Summary 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	12,349,787	10,351,703	0	1,998,084	0	0
Annual Time Burden (Hours)	1,028,737	780,918	0	247,819	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total annual hour burden has increased due to an increase in the number of respondents and increased episodes of care

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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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