CMS-417 Final Supporting Statement Part A 090214

SUPPORTING STATEMENT FOR THE

HOSPICE REQUEST FOR CERTIFICATION (CMS-417) AND SUPPORTING REGULATIONS

A. BACKGROUND

This is a request for a 3 year revision extension of approval for the CMS-417, the Hospice Request for Certification in the Medicare Program which is currently approved under OMB # 0938-0313.

The certification form is an identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program. If a provider meets these preliminary requirements, a survey is scheduled to determine if the provider complies with the conditions of participation required by the Medicare program. The data on this form serve as a basis for the inspection. The facility is only required to complete certain items on the certification forms as indicated by the instructions included with the form. These items are explained below.

_{B. JUSTIFICATION}

1. Need and Legal Basis

This activity is authorized by section 122 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (Public Law 97-248) and section 1861(dd) of the Social Security Act, which allow hospice entities to participate as Medicare providers of services if the entities meet regulatory conditions of participation.

For Medicare purposes, certification is based on the State survey agency's reporting of the provider's compliance or noncompliance with the health and safety requirements published in regulations. To determine compliance with the requirements, the Secretary has authorized States through contracts to conduct surveys of these providers.

This certification form is used in the initial stages of the survey process to gather and record minimum identification information into the Online Survey, Certification, and Reporting (OSCAR) System in the State and at the central and regional offices of the Centers for Medicare and Medicaid Services (CMS).

Section 1861(dd) of the Social Security Act (the Act) defines Hospice Care and Hospice Program with respect to The Medicare Hospice Benefit. 42 CFR 418 sets forth the Health and Safety Conditions of Participation (CoPs) that all Hospices must meet to participate in Medicare. State survey agencies are used by CMS to

determine if the CoPs are met.

2. Information Users

The information from this form will be used by CMS in making initial certification and subsequent recertification decisions. Initially, when a hospice expresses an interest in participating in the Medicare program, it contacts the State agency which forwards the Request for Certification (CMS-417) to the applicant. The state agency for each state is listed at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf. Alternatively, the form is available online at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS417.pdf, and can be submitted to the State agency via email. The information on the form serves as a screen for the State agency to determine if the hospice has the basic capabilities to participate in the Medicare program, and whether a survey is appropriate. At the time of the recertification, the form is also completed by the hospice and given to the surveyor, so that the necessary identification and operational data (such as the number and types of staff, types of services, and other information to assist the surveyors in selecting a sample of patients) may be revised in the event that there have been changes. The identifying information from this form is coded into the OSCAR system and serves as the information base for the creation of a record for future Federal certification and monitoring activity.

_{3. Improved Information Technology}

The certification form lists minimum criteria that must be met in order to be approved for Medicare participation. The standardized format and simple checkbox method provide for consistent reporting by State survey agencies. Recording this information would be no easier for State surveyors using direct access equipment.

4. Duplication of Similar Information

This certification form does not duplicate any information collection. The form addresses specific requirements for certification. State survey agencies conduct these reviews with Federal funds under contract with CMS. This form is a basic deliverable under these contracts and is the only one of its kind collected by CMS for hospices.

_{5. Small Business}

This form is completed by small businesses, but is a necessary data collection, with minimal burden imposed.

6. Less Frequent Collection

Submission of the certification form is based on the frequency of surveys. These surveys, in turn, depend on the frequency specifications of regulations and the availability of survey funds.

7. Special Circumstances

_{There are no special circumstances.}

_{8. Federal Register Notice/Outside Consultation}

A 60-day Federal Register notice was published on November 1, 2013. No comments were received. No additional outside consultation was made as this is not a new collection and no substantial changes have been made since the last submission.

9. Payment Gift to Respondent

_{There are no payment/gifts to respondents.}

_{10. Confidentiality}

We do not pledge confidentiality.

11. Sensitive Questions

_{There are no questions of a sensitive nature on the form.}

_{12. Burden Estimate (Total Hrs. & Wage)}

Initially, this form is completed by the facility expressing an interest in participating in the Medicare program. (Thereafter, it is completed by the hospice, during the unannounced survey, and given to the State agency surveyor.) We estimate, based on the simplicity of the form and past usage, that it takes approximately 15 minutes (0.25 hr) to complete (the form is available online and would take a few minutes to download. The information needed to complete the form should be readily available to the hospice, requiring no research or analysis).

1,168 Hospices completing the form (FY 2012)

x .25 Hours to complete form

_{292 Hours (annual) of burden for completion of form}

_{On an annual basis, only hospices applying for initial certification and re-certification for Medicare participation—321 Hospices (FY 2013 initial surveys) plus 847 standard surveys for a total of 1,168 required surveys and associated form completions.}

_{Public Cost}

The financial cost to the public rests solely with the time/salary element of hospice employees that complete the request for certification.

292 hours x $68.00 (professional hourly wage for Federal calculationsⁱ) = $19,846 .

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

There are no Federal costs anticipated since the form will no longer be printed as a multi-part form, but rather available on-line.

_{15. Program/Burden Changes}

The burden is reduced to include only those hospices involved in initial or recertification, rather than all hospices. In 2013, this included 1,168 hospices

16. Publication and Tabulation Dates

_{There are no publication and tabulation dates.}

_{17. Expiration Date}

CMS would like an exemption to displaying the expiration date. The form is used on a continuing basis and it would uneconomical to have to revise and reprint it every three years and to destroy expired forms.

18. Certification Statement

_{There are no exceptions to the certification statement.}

_{C. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS}

There are no statistical methods employed in the information collected.

i This cost is based on the FY 2015 Hospice Wage Index and Payment Rate Update, published August 22, 2014, in the Federal Register, Vol. 79, No. 163, p. 50500. The hourly wage is for the hospice administrator, as the authorized hospice representative that might be the responsible signatory.

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