Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Responses to comments.xlsx	Supplementary Document	Uploaded 2013-11-22	Available
CMS-1984-14-Revisions Crosswalk from old to new.doc	Supplementary Document	Uploaded 2013-11-22	Available
CMS-1984-14 - Supporting Statement Part A [rev 11-22-2013].doc	Supporting Statement A	Uploaded 2013-11-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8476	Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24	Instruction	Modified

ICR Details

OMB Control No: 0938-0758	ICR Reference No: 201312-0938-003
Status: Historical Active	Previous ICR Reference No: 201011-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 21002
Title: Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 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: 02/06/2014
	Date Received in OIRA: 12/06/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved	02/28/2014
Responses	2,751	0	2,303
Time Burden (Hours)	517,188	0	405,328
Cost Burden (Dollars)	0	0	0

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Abstract: The Hospice Cost and Data Report provides for the collection of data from providers for rate evaluations for the Prospective Payment System (PPS). The data is used by CMS to update the PPS as mandated by Congress.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1815 Name of Statute: null
   Statute at Large: 18 Stat. 1833 Name of Statute: null
   Statute at Large: 18 Stat. 1861 Name of Statute: null
   Statute at Large: 18 Stat. 1881 Name of Statute: null
  

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 25089	04/29/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 70057	11/22/2013
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
Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24	CMS-1984-14	Hospice Cost Report

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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	2,751	2,303	0	0	448	0
Annual Time Burden (Hours)	517,188	405,328	0	896	110,964	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The total burden for the new Form CMS-1984-14 is estimated to be 517,188 hours and $10,343,760. This is an increase of 111,860 hours and $2,237,200. The changes to the burden are a result of: o On a per respondent basis, revisions to the MCR to facilitate hospice payment reform 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 2 hours for this information collection. (However, the overall burden to the provider decreased by 14 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 448 (from 2,303 as of June 21, 2010 to 2,751 as of April 4, 2013).

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Annual Cost to Federal Government: $454,650

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: 12/06/2013

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