Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-2540-10 Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary	Form	Modified	Repair queued
pr2_4100_to_4107 Crosswalk.doc	Supplementary Document	Uploaded 2011-07-14	Available
pr2_4195 Crosswalk.doc	Supplementary Document	Uploaded 2011-07-14	Available
CMS-2540 Crosswalk.xlsx	Supplementary Document	Uploaded 2011-07-13	Available
CMS-2540 Supporting Statement [rev 10-18-11].doc	Supporting Statement A	Uploaded 2011-10-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8084	Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	Form	Modified	Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary
8084	Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	Instruction	Modified

ICR Details

OMB Control No: 0938-0463	ICR Reference No: 201107-0938-006
Status: Historical Active	Previous ICR Reference No: 201006-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/23/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/19/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	36 Months From Approved	08/31/2013
Responses	15,701	0	15,037
Time Burden (Hours)	3,171,602	0	2,706,660
Cost Burden (Dollars)	0	0	0

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Abstract: Form CMS 2540-10 is used by Skilled Nursing Facilities (SNFs) and Skilled Nursing Facility Complexes participating in the Medicare program to report the health care costs to determine the amount of reimbursable costs for services rendered to Medicare beneficiaries.

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Authorizing Statute(s): US Code: 42 USC 1395g Name of Law: Payments to providers of services
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 aaa Name of Law: Patient Protection and Affordable Care Act

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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:
	76 FR 13415	03/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38657	07/01/2011
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
Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	CMS-2540-10	Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary

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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	15,701	15,037	0	0	664	0
Annual Time Burden (Hours)	3,171,602	2,706,660	94,206	251,216	119,520	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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The Patient Protection and Affordable Care Act, ? 6104(1) of Public Law 111-148 amended 1888(f) of the Social Security Act ("Reporting of Direct Care Expenditures"), requires SNFs to separately report expenditures for wages and benefits for direct care staff (breaking out (at a minimum) registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff). In implementing these changes Worksheet S-3, part V was added. With the addition of this worksheet the average record keeping time for each provider will be increased by 5 hours and the average reporting time by 1 hour. An increase in burden is also due to a change in the number of respondents.

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Annual Cost to Federal Government: $23,635,500

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]? 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: 07/19/2011

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