Home Health Change of Care Notice (HHCCN)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10280 Notice	Form	New	Available
Response to Comments for CMS-10280.docx	Supplementary Document	Uploaded 2013-03-07	Available
CMS-10280_HHCCN_Supporting_StatementOCT2012v508.pdf	Supporting Statement A	Uploaded 2013-03-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206099	Notice	Form	New

ICR Details

OMB Control No: 0938-1196	ICR Reference No: 201303-0938-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 19118
Title: Home Health Change of Care Notice (HHCCN)
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: 06/10/2013
	Date Received in OIRA: 03/11/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	14,126,428	0	0
Time Burden (Hours)	941,385	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare and Medicaid Services (CMS) requests a new collection named the Home Health Change of Care Notice (HHCCN), Form CMS -10280, to replace, in part, the existing, previously approved Office of Management and Budget (OMB) notice, titled the Home Health Advance Beneficiary Notice (HHABN) (CMS-R-296). The use of written notices to inform beneficiaries of their liability under specific conditions has been available since the "limitation on liability" provisions in ?1879 of the Act were enacted in 1972 (P.L. 92-603). The revised Advanced Beneficiary Notice of Noncoverage (ABN) for conveying information on beneficiary liability is approved by OMB, consistent with the Paperwork Reduction Act of 1995 (PRA); however, HHAs have been historically excluded from using the ABN as a liability notice for their services and have used the HHABN exclusively. In an effort to streamline, reduce, and simplify appeals notices issued to Medicare beneficiaries, the appeals portion of the HHABN will be replaced by the existing ABN (CMS -R-131) which is presently used by providers other than HHAs to inform Fee For Service (FFS) Medicare beneficiaries of potential liability for certain items/services that might be billed to Medicare. Pursuant to a separate PRA package revising the use of the ABN, HHAs will now use the ABN for liability notification, and the HHCCN will be introduced as a separate, distinct document to give change of care notice in compliance with HHA COPs.

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Authorizing Statute(s): US Code: 42 USC 1395bbb Name of Law: CONDITIONS OF PARTICIPATION FOR HOME HEALTH AGENCIES; HOME HEALTH QUALITY
  

Citations for New Statutory Requirements: US Code: 42 USC 1395bbb Name of Law: CONDITIONS OF PARTICIPATION FOR HOME HEALTH AGENCIES; HOME HEALTH QUALITY

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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:
	77 FR 74018	12/12/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 13058	02/26/2013
Did the Agency receive public comments on this ICR? Yes

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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
Notice	CMS-10280	Home Health Change of Care Notice

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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	14,126,428	0	14,126,428	0	0	0
Annual Time Burden (Hours)	941,385	0	941,385	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 request.

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Annual Cost to Federal Government: $0

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: 03/11/2013

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