Supporting Statement for
CMS-29
Verification of Clinic Data – Rural Health Clinic Program Form and Supporting Regulations
A. Background
The information collection requirements that are included with this request are for the currently approved collection, Verification of Clinic Data – Rural Health Clinic Program Form CMS-29 (for which extension of previous approval is being requested).
The Form CMS-29, Verification of Clinic Data – Rural Health Clinic Program is utilized as an application to be completed by suppliers of Rural Health Clinic (RHC) services requesting participation in the Medicare program. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services. It also promotes data reduction or introduction to and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices (ROs). Should any question arise regarding the structure of the organization, this information is readily available.
Both new and existing clinics must provide and attest to the accuracy of specific clinic data as a part of the RHC certification process. Therefore, we are requesting to extend the existing approval.
B. Justification
1. Need and Legal Basis
Collection of this information is authorized by 42 CFR 491.1 through 491.11 pursuant to sections 1864 and 1875 of the Social Security Act. Organizations rendering RHC services may participate as Medicare suppliers. In order to determine compliance with the conditions for certification (CfC), the Secretary has authorized States through contracts to conduct surveys of health care suppliers. For Medicare purposes, certification is based on the State agency's recording and reporting to CMS of a supplier's compliance or noncompliance with health and safety requirements.
The Verification of Clinic Data – Rural Health Clinic Program, Form CMS-29, is a certification form provided by the State agency to those clinics seeking Medicare certification as a RHC. It is completed and returned by the applicant and evaluated subsequently through an on-site survey. The State agency has an inspector/surveyor review the facility's compliance with the RHC CfCs. The verification form also details the clinic information which will be stored in the ASPEN and related survey and certification databases. The storage of the information allows for later retrieval for study reports and data collection.
2. Information Users
CMS uses the collected information to inform its certification and recertification decisions. When a clinic seeks certification in the Medicare program as a RHC, the State agency forwards the Verification of Clinic Data (CMS-29) to the clinic which completes and returns the form. The information on the completed form serves as an initial screening tool for the State agency to determine if the clinic appears to satisfy basic certification requirements and is ready for a more detailed on-site compliance assessment.
3. Improved Information Technology
The basic identifying information from this form is incorporated into ASPEN and related survey and certification databases and serves as the information base for the creation of a record for future Federal recertification and analytical activity.
4. Duplication of Similar Information
The CMS-29 does not duplicate any information collection. The form addresses unique regulatory CfCs that RHCs must meet to participate in the Medicare program. State agencies receive Federal funds for conducting these reviews 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 RHC suppliers.
5. Small Business
Some RHCs may be small businesses. The information collected is needed to assist in determining the RHC’s compliance with the CfCs. Collection of this information imposes a minimal burden and thus does not significantly affect small businesses.
6. Less Frequent Collection
This information is collected prior to the clinic’s initial certification, and subsequently once every six years on average, when the State agency conducts a recertification survey. Less frequent surveys and associated verification of the Form CMS-29 could reduce quality assurance protections to Medicare beneficiaries.
7. Special Circumstances for Information Collection
There are no special circumstances associated with this collection. These requirements comply with all general information collection guidelines in 5 CFR 1320.6.
8. Federal Register and Outside Consultation
A 60-day Federal Register notice was published on January 23, 2015. There were no comments received. We have not sought outside consultations via the paperwork reduction act of 1995 in reference to this form since the last OMB approval.
9. Payments or Gifts
There are no payments of gifts associated with this collection.
10. Confidentiality
We do not pledge confidentially
11. Sensitive Questions
There are no questions of a sensitive nature associated with this form.
12. Estimate of Burden
There are 4,200 RHCs enrolled in Medicare currently. All new clinics must complete the Form CMS-29. There are approximately 200 new RHCs annually. Existing clinics must complete the CMS-29 in conjunction with a recertification survey every six years on average, which equals approximately 700 recertification surveys annually. Thus approximately 900 Form CMS-29s are collected each year.
Verification Form
Based on past usage of this form and the general nature of the questions, we estimate that it takes the RHC approximately 10 minutes to complete this form. Total annual burden for the form is 138 hours. (900 suppliers times 10 minutes per form equals 9,000 minutes or 150 hours.)
The total burden for CMS-29 is 150 hours. We estimate that the information collection requirements will cost the public 3,750 (150 hours times $25.00 per hour)
13. Annualized Cost of Burden
There are no annualized costs associated with this collection.
14. Federal Cost Estimates
Total Federal Cost - $4,650.00*
Number of suppliers in universe 4,200
Number of suppliers completing form annually 900
Contracting costs to complete forms $3,750*
Printing of forms CMS-29 and Distribution:
CMS-29 $900*
* The amount for completion of forms was calculated using an average hourly salary of $25.00/hour for state inspectors, an average of 0.1667 hours for surveyors’ verification, and an annual workload of 900.
15. Burden Changes/Program changes
There has been modest growth in the total number of RHCs. The number of RHCs actually completing the form annually has increased from 830 to 900.
16. Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. OMB Expiration Date
CMS does not object to displaying the OMB expiration date.
| File Type | application/msword |
| File Title | Supporting Statement for |
| Author | CMS |
| Last Modified By | Denise King |
| File Modified | 2015-04-06 |
| File Created | 2015-01-16 |