SUPPORTING STATEMENT
FOR THE
HOSPICE REQUEST FOR CERTIFICATION (CMS-417)
AND SUPPORTING REGULATIONS
A. BACKGROUND
This is a request for a 3 year extension of approval for the CMS-417, the Hospice Request for Certification in the Medicare Program which is currently approved under OMB # 0938-0313.
The certification form is an identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program. If a provider meets these preliminary requirements, a survey is scheduled to determine if the provider complies with the conditions of participation required by the Medicare program. The data on this form serve as a basis for the inspection. The facility is only required to complete certain items on the certification forms as indicated by the instructions included with the form. These items are explained below.
B. JUSTIFICATION
1. Need and Legal Basis
This activity is authorized by section 122 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (Public Law 97-248) and section 1861(dd) of the Social Security Act, which allow hospice entities to participate as Medicare providers of services if the entities meet regulatory conditions of participation. For Medicare purposes, certification is based on the State survey agency's reporting of the provider's compliance or noncompliance with the health and safety requirements published in regulations. To determine compliance with the requirements, the Secretary has authorized States through contracts to conduct surveys of these providers.
This certification form is used in the initial stages of the survey process to gather and record minimum identification information into the Online Survey, Certification, and Reporting (OSCAR) System in the State and at the central and regional offices of the Centers for Medicare and Medicaid Services (CMS).
Section 1861(dd) of the Social Security Act (the Act) defines Hospice Care and Hospice Program with respect to The Medicare Hospice Benefit. 42 CFR 418 sets forth the Health and Safety Conditions of Participation (CoPs) that all Hospices must meet to participate in Medicare. State survey agencies are used by CMS to determine if the CoPs are met.
2. Information Users
The information from this form will be used by CMS in making initial certification and subsequent recertification decisions. Initially, when a hospice expresses an interest in participating in the Medicare program, it contacts the State agency which forwards the Request for Certification (CMS-417) to the applicant. The information on the form serves as a screen for the State agency to determine if the hospice has the basic capabilities to participate in the Medicare program, and whether a survey is appropriate. At the time of the recertification, the form is also completed so that the necessary identification data may be revised in the event that there have been changes. The identifying information from this form is coded into the OSCAR system and serves as the information base for the creation of a record for future Federal certification and monitoring activity.
3. Improved Information Technology
The certification form lists minimum criteria that must be met in order to be approved for Medicare participation. The standardized format and simple checkbox method provide for consistent reporting by State survey agencies. Recording this information would be no easier for State surveyors using direct access equipment.
4. Duplication of Similar Information
This certification form does not duplicate any information collection. The form addresses specific requirements for certification. State survey agencies conduct these reviews with Federal funds 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 hospices.
5. Small Business
This form is completed by small businesses, but is a necessary data collection, with minimal burden imposed.
6. Less Frequent Collection
Submission of the certification form is based on the frequency of surveys. These surveys, in turn, depend on the frequency specifications of regulations and the availability of survey funds.
7. Special Circumstances
There are no special circumstances.
8. Federal Register Notice/Outside Consultation
A 60-day Federal Register notice was published on 09/03/2010 (75 FR 54149). No comments were received. No additional outside consultation was made as this is not a new collection and no substantial changes have been made since the last submission.
9. Payment Gift to Respondent
There are no payment/gifts to respondents.
10. Confidentiality
We do not pledge confidentiality.
11. Sensitive Questions
There are no questions of a sensitive nature on the form.
12. Burden Estimate (Total Hrs. & Wage)
Initially, this form is completed by the facility expressing an interest in participating in the Medicare program. (Thereafter, it is completed by the State agency surveyor.) We estimate, based on the simplicity of the form and past usage, that it takes approximately 15 minutes (0.25 hr) to complete.
3,494 Hospices completing the form (CY 2009)
x .25 Hours to complete form
873.5 Hours (annual) of burden for completion of form
Public Cost
The financial cost to the public rests solely with the time/salary element of hospice employees that complete the request for certification.
874 hours x $40.00 (professional hourly wage for Federal calculations) = $34,960.
13. Capital Costs
There are no capital costs.
14. Cost to Federal Government
Federal cost involvement with the request for eligibility form relates only to printing costs. The form (CMS-417) is a one-page form with three carbon duplicate pages and a one-page instruction sheet.
Total pages = 5
Total costs = 5 pages per form x 5,160 forms =25,800 pages x $.20 per page (standard government calculation rate per printed page) = $5,160.
15. Program/Burden Changes
There are no program or burden changes. There is an annual response/burden increase resulting from mathematical error.
On form CMS-417, under section V, the identification number for entry Licensed Practical Nurses/ Licensed Vocational Nurses has been renumbered to read “PH13”.
16. Publication and Tabulation Dates
There are no publication and tabulation dates.
17. Expiration Date
CMS would like an exemption to displaying the expiration date. The form is used on a continuing basis and it would uneconomical to have to revise and reprint it every three years and to destroy expired forms.
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 the information collected.
| File Type | application/msword |
| Author | HCFA Software Control |
| Last Modified By | Mitch |
| File Modified | 2010-12-02 |
| File Created | 2010-11-16 |