Medicaid Disproportionate Share Hospital Annual Reporting (CMS-R-266)

ICR 201104-0938-006

OMB: 0938-0746

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2011-04-25
Supporting Statement A
2011-04-25
IC Document Collections
ICR Details
0938-0746 201104-0938-006
Historical Active 200806-0938-005
HHS/CMS
Medicaid Disproportionate Share Hospital Annual Reporting (CMS-R-266)
Extension without change of a currently approved collection   No
Regular
Approved without change 05/10/2011
Retrieve Notice of Action (NOA) 04/27/2011
  Inventory as of this Action Requested Previously Approved
05/31/2014 36 Months From Approved 08/31/2011
52 0 52
1,976 0 1,976
0 0 0

Section 1923(a)(2)(D) of the Act requires the States to submit an annual report that identifies each DHS payment under the State's Medicaid program in the preceding fiscal year and the amount of DSH payments paid to that hospital in the same year and such other information as the Secretary determines necessary to ensure the appropriateness of DHS payments. The information supplied will satisfy the requirements under section 1923(a)(2)(D) of the Act as well.

PL: Pub.L. 108 - 173 1001 Name of Law: Medicare Modernization Act
   Statute at Large: 19 Stat. 1923 Name of Statute: null
  
None

Not associated with rulemaking

  76 FR 3909 01/21/2011
76 FR 18223 04/01/2011
No

1
IC Title Form No. Form Name
Medicaid Disproportionate Share Hospital Annual Reporting

  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 52 52 0 0 0 0
Annual Time Burden (Hours) 1,976 1,976 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$825
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/27/2011


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