Current State Practices Related to Payments to Providers for Health Care-Acquired Conditions

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10335 HCAC Survey	Form and Instruction	New	Available
CMS-10335.Supporting Statement - Part B.doc	Supporting Statement B	Uploaded 2011-01-05	Available
CMS-10335 Supporting Statement - Part A.doc	Supporting Statement A	Uploaded 2011-01-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
195880	HCAC Survey	Form and Instruction	New

ICR Details

OMB Control No: 0938-1122	ICR Reference No: 201101-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Current State Practices Related to Payments to Providers for Health Care-Acquired Conditions
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/21/2011
	Date Received in OIRA: 01/05/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved
Responses	50	0	0
Time Burden (Hours)	50	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), enacted March 23, 2010 includes provisions prohibiting Federal Financial Participation to States for payments for health care-acquired conditions (HCACs). Section 2702(a) specifically requires that the Secretary identify current State practices that prohibit payment for HCACs and incorporate those practices or elements of those practices which she determines appropriate for application to the Medicaid program. In accordance with section 2702(a) of the Affordable Care Act, CMS is issuing this survey to States to obtain information on current State Medicaid practices for prohibiting payments for HCACs.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2702 Name of Law: Payment Adjustment for Health Care-Acquired Conditions
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2702 Name of Law: Payment Adjustment for Health Care-Acquired Conditions

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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:
	75 FR 39696	07/12/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 63485	10/15/2010
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
HCAC Survey	CMS-10335	HCAC Survey

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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	50	0	50	0	0	0
Annual Time Burden (Hours)	50	0	50	0	0	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: This is a new information collection reqeust.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 01/05/2011

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