Community Mental Health Center (CMHC) Cost Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-2088-17 Community Mental Health Cost (CMHC) Report	Form	Modified	Available
PRA CMS-2088 SS_508 Compliant - Passback3_kjw-Final.docx	Supporting Statement A	Uploaded 2018-05-02	Available
Reply to comments 2088-17.pdf	Supplementary Document	Uploaded 2017-07-26	Available
Worksheet Crosswalk.pdf	Supplementary Document	Uploaded 2017-07-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7791	Community Mental Health Cost (CMHC) Report	Form	Modified

ICR Details

OMB Control No: 0938-0037	ICR Reference No: 201707-0938-013
Status: Active	Previous ICR Reference No: 201401-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-2088-17
Title: Community Mental Health Center (CMHC) Cost Report
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/04/2018
	Date Received in OIRA: 07/27/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved
Responses	219	0	0
Time Burden (Hours)	19,710	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In addition, regulations at 42 CFR 413.20 and 413.24 require adequate cost data and cost reports from providers on an annual basis. The Form CMS-2088-17 cost report is needed to determine a provider’s reasonable costs incurred in furnishing medical services to Medicare beneficiaries and reimbursement due to or due from a provider.

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Authorizing Statute(s): 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. 1815 Name of Statute: null
   US Code: 42 USC 1393g Name of Law: 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:
	82 FR 2997	01/10/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 34675	07/26/2017
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
Community Mental Health Cost (CMHC) Report	CMS-2088-17	Community Mental Health Cost (CMHC) 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	219	0	0	0	-321	540
Annual Time Burden (Hours)	19,710	0	0	0	-34,290	54,000
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: The forms are revised to remove obsolete worksheets for certified outpatient physical therapy, outpatient occupational therapy and outpatient speech pathology providers, and comprehensive outpatient rehabilitation facilities that no longer have a cost report filing requirement. In addition, the forms are revised to incorporate data previously reported on OMB No. 0938-0301, the Provider Cost Report Reimbursement Questionnaire, Form CMS-339.

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Annual Cost to Federal Government: $701,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 07/27/2017

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