Electronic Submission of Medicare GME Affiliation Agreements

Forms and Documents

Document Name	Status
Form CMS-10326 Electronic Submission to CMS Form	Modified
Form CMS-10326 Hardcopy Submission to FI or MAC Form	Modified
Form CMS-10326 Development of Agreement Form	Modified
CMS-10326 - Supporting_Statement Part A [rev 10-21-2013 by OSORA PRA].docx Supporting Statement A	2013-10-21

IC Document Collections

IC ID	Document Title	Status
193422	Electronic Submission to CMS Form	Modified
193421	Hardcopy Submission to FI or MAC Form	Modified
193420	Development of Agreement Form	Modified

ICR Details

OMB Control No: 0938-1111	ICR Reference No: 201310-0938-002
Status: Historical Active	Previous ICR Reference No: 201009-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 20696
Title: Electronic Submission of Medicare GME Affiliation Agreements
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: 04/21/2014
	Date Received in OIRA: 10/25/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	04/30/2014
Responses	375	0	375
Time Burden (Hours)	166	0	166
Cost Burden (Dollars)	0	0	0

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Abstract: As discussed in the FY2011 Inpatient Prospective Payment System final rule, we will allow hospitals to electronically submit the copy of the affiliation agreement that is required to be sent to the CMS Central Office. The electronic submission process consists of either an email mailbox or a Web site where hospitals must submit their Medicare GME affiliation agreements to the CMS Central Office to a designated online mailbox. A copy of the Medicare GME affiliation agreement must be received through the electronic system no later than 11:59 p.m. on July 1 of each academic year. The electronic affiliation agreement must be submitted either as a scanned copy or a Printer-Friendly Display (PDF) version of that hard copy agreement; we will not accept an agreement in any electronic format that could be subject to manipulation. The scanned and/or PDF format will enable CMS to ensure that the agreements are signed and dated as required in the regulations at 42 CFR 413.75. Hospitals will have the option to continue to submit a hard copy of its affiliation agreement to the CMS Central Office. In addition, each fiscal intermediary or MAC will continue to have the authority to specify its requirements for submittal of the Medicare GME affiliation agreement by hospitals that are part of the affiliation.

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Authorizing Statute(s): PL: Pub.L. 105 - 32 4623 Name of Law: Limitation of Number of Residents and Rolling Average FTE Count
   US Code: 42 USC 1395ww Name of Law: Payment to Hospitals for Inpatient Hospital Services
  

Citations for New Statutory Requirements: None

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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:
	78 FR 45205	07/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Hardcopy Submission to FI or MAC	CMS-10326	SAMPLE Affiliation Agreement
Electronic Submission to CMS	CMS-10326	SAMPLE Affiliation Agreement
Development of Agreement	CMS-10326	SAMPLE Affiliation Agreement

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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	375	375	0	0	0	0
Annual Time Burden (Hours)	166	166	0	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:

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Annual Cost to Federal Government: $5,972

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: 10/25/2013

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