Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detaile

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10066 Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)	Form and Instruction	Modified	Available
Crosswalk Document for Changes to DND.doc	Supplementary Document	Uploaded 2010-04-20	Available
CMS-10066_Supporting_Statement_Detailed_Notice_2010dec17th_OMB CommentsQuestions (2).doc	Supporting Statement A	Uploaded 2010-07-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
179807	Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1019	ICR Reference No: 201005-0938-006
Status: Historical Active	Previous ICR Reference No: 200706-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detaile
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: 07/20/2010
	Date Received in OIRA: 05/13/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	07/31/2010
Responses	13,218	0	130,000
Time Burden (Hours)	13,218	0	130,000
Cost Burden (Dollars)	0	0	0

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Abstract: Based on a settlement agreement of the Weichardt vs. Leavitt class action suit, CMS-4105-F sets forth new requirements for how hospitals must notify Medicare beneficiaries who are hospital inpatients about their hospital discharge rights. Pursuant to sections 405.1206 and 422.622, hospitals and Medicare Advantage plans must deliver to beneficiaries and enrollees, who are appealing inpatient hospital discharges, a detailed notice providing the reasons for the discharge decision. Notice is required both for original Medicare beneficiaries and for beneficiaries enrolled in Medicare Advantage plans and other Medicare health plans subject to the MA regulations.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1154 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:
0938-AO41	Final or interim final rulemaking	71 FR 68708	11/27/2007

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 3907	01/25/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 20367	04/19/2010
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 and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)	CMS-10066, CMS-10066	Detailed Notice of Discharge ,   Aviso Detallado Sobre Dado De Alta

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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	13,218	130,000	0	0	-116,782	0
Annual Time Burden (Hours)	13,218	130,000	0	0	-116,782	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 DND was submitted for OMB approval as a new collection in 2007, and we had predicted that 130,000, or 1% of the 13 million Medicare beneficiaries discharged would receive a DND. Since implementation of the DND and revised Important Message from Medicare (IM) began in July 2007, we selected QIO data from 2008 to reflect a full calendar year of use. In 2008 a total of 13, 218 or 0.1075% of the annual discharges required DND delivery.

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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]? No

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: 05/13/2010

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