Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24

Forms and Documents

Document	Type	Status	Availability
draft - Response to Comments to OMB.doc	Supplementary Document	Uploaded 2011-10-12	Repair queued
2011 ESRD Disclosure Statement.DOC	Supplementary Document	Uploaded 2011-10-12	Repair queued
CMS-265-11Revisions - Crosswalk from old to new.doc	Supplementary Document	Uploaded 2011-10-12	Repair queued
CMS-265-11 - Supporting Statement part A [rev 10-12-11].doc	Supporting Statement A	Uploaded 2011-10-12	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
7893	Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178	Instruction	Modified

ICR Details

OMB Control No: 0938-0236	ICR Reference No: 201110-0938-007
Status: Historical Active	Previous ICR Reference No: 201008-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/28/2011
	Date Received in OIRA: 10/14/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved	10/31/2013
Responses	5,654	0	5,508
Time Burden (Hours)	367,510	0	275,400
Cost Burden (Dollars)	0	0	0

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Abstract: The Independent Renal Dialysis Facility Cost Report provides for the determination and allocation of costs to the components of the facility in order to establish a proper basis for Medicare payment.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 153 Name of Law: Medicare Improvements for Patients and Providers Act
   US Code: 42 USC 1395g Name of Law: Payment of Providers of Services
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 153 Name of Law: Medicare Improvements for Patients and Providers 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 18222	04/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 62414	10/07/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178	CMS-265-11	Independent Renal Dialysis Facility Cost Report

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ICR Summary 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	5,654	5,508	0	0	146	0
Annual Time Burden (Hours)	367,510	275,400	55,445	27,175	9,490	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 forms are revised in accordance with the End-Stage Renal Disease Prospective Payment System Final Rule published August 12, 2010 which implemented statutory requirements of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. Additionally, the forms are revised to incorporate data previously reported on the Provider Cost Report Reimbursement Questionnaire, Form CMS-339. o On a per respondent basis, revisions to the MCR to implement ESRD PPS resulted in an increase in burden of 10 hours. o On a per respondent basis, incorporating the Form CMS-339 into the revised MCR resulted in an increase in burden of 5 hours for this information collection. (However, the overall burden to the provider decreased by 11 hours as a result of eliminating the paper Form CMS-339, for which the burden was estimated at 16 hours.) o The estimated number of respondents increased by 146 (from 5,508 as of 03/15/2010 to 5,654 as of 03/04/2011).

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Annual Cost to Federal Government: $44,715,900

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]? 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: 10/14/2011

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