Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare

Forms and Documents

Document Name	Status
Form CMS-R-193 Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193) Form and Instruction	Modified
CMS-R-193 and CMS-10066.Response to 60-day comments.docx Supplementary Document	2013-05-20
CMS-R-193.Supporting Statement Part A.docx Supporting Statement A	2013-05-20

IC Document Collections

IC ID	Document Title	Status
8309	Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0692	ICR Reference No: 201305-0938-016
Status: Historical Active	Previous ICR Reference No: 201005-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 19640
Title: Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/26/2013
	Date Received in OIRA: 05/22/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	07/31/2013
Responses	19,840,000	0	19,680,000
Time Burden (Hours)	2,976,000	0	2,952,000
Cost Burden (Dollars)	0	0	0

---

Abstract: As a result of the Weichardt v. Leavitt class action lawsuit and in response to public comments, CMS set forth a final rule in November 2006, CMS-4105-F, for how hospitals must notify Medicare beneficiaries who are hospital inpatients about their hospital discharge rights. Notice is required both for original Medicare beneficiaries and for beneficiaries enrolled in Medicare Advantage plans and other Medicare health plans subject to the MA regulations. Under the final rule, hospitals use a revised version of the Important Message from Medicare (IM), Form CMS-R-193 to explain discharge rights. Hospitals must issue the IM within two days of admission, and must obtain the signature of the beneficiary or his or her representative. Hospitals must also deliver a copy of the signed notice to each beneficiary not more than two days before the day of discharge. This notice was approved in 2007 to fulfill the regulatory requirement

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1866 Name of Statute: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 14555	03/06/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 29315	05/17/2013
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare (CMS-R-193)	CMS-R-193, CMS-R-193	Important Message from Medicare ,   Mensaje Importante De Medicare Sobre Sus Derechos

---

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	19,840,000	19,680,000	0	0	160,000	0
Annual Time Burden (Hours)	2,976,000	2,952,000	0	0	24,000	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: The burden increased slightly due to an adjustment in the number of respondents.

---

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

---

Common Form ICR:  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:

(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: 05/22/2013

---