Evaluation of the Rural Community Hospital Demonstration

Forms and Documents

Document	Type	Status	Availability
Form CMS-10508 RCHD Hospital Interview Protocols and Annual Progress Report Template -- public hospitals	Form and Instruction	New	Repair queued
Form CMS-10508 RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals	Form and Instruction	New	Available
CMS-10508 supporting_statement 7Nov2013 final.docx	Supporting Statement A	Uploaded 2014-01-28	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
210348	RCHD Hospital Interview Protocols and Annual Progress Report Template -- public hospitals	Form and Instruction	New
210347	RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals	Form and Instruction	New

ICR Details

OMB Control No: 0938-1253	ICR Reference No: 201402-0938-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 21348
Title: Evaluation of the Rural Community Hospital Demonstration
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 with change	Conclusion Date: 10/15/2014
	Date Received in OIRA: 02/12/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved
Responses	33	0	0
Time Burden (Hours)	245	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Rural Community Hospital (RCH) Demonstration was originally authorized by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and implemented from 2004-2011, and was recently extended by the Patient Protection and Affordable Care Act of 2010. The demonstration was developed to provide enhanced reimbursement for inpatient services to small rural hospitals that do not qualify as critical access hospitals (CAHs) and to increase the capability of these hospitals to meet the health care needs of rural beneficiaries in their service areas. Through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the Affordable Care Act of 2010, Congress instructed CMS to provide information that can be used to assess the feasibility and advisability of establishing a new category of rural community hospitals for reimbursement policy. Hospital interviews and annual progress reports with each participating hospital will be used to collect information on hospital operations, environmental contexts, challenges, goals for participating in the demonstration, use of demonstration funds, and benefits provided to the community.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 410 Name of Law: MMA
   PL: Pub.L. 111 - 148 10313 Name of Law: Affordable Care Act
  

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 68851	11/15/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 3818	01/23/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals	CMS-10508	Data Collection Protocols
RCHD Hospital Interview Protocols and Annual Progress Report Template -- public hospitals	CMS-10508	Data Collection Protocols

---

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	33	0	0	33	0	0
Annual Time Burden (Hours)	245	0	0	245	0	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: This is a new information collection.

---

Annual Cost to Federal Government: $31,102

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]? Yes

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: 02/12/2014

---