Rural Health Clinic Cost Report

Forms and Documents

Document Name	Status
CMS-222-17 crosswalk.pdf Supplementary Document	2017-09-29
Supporting Statement_222-17 revised yf (1) - Passback_Final.docx Supporting Statement A	2018-04-25

IC Document Collections

IC ID	Document Title	Status
7853	Rural Health Clinic Cost Report CMS-222-17 Instruction	Modified

ICR Details

OMB Control No: 0938-0107	ICR Reference No: 201709-0938-008
Status: Active	Previous ICR Reference No: 201408-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-222-17
Title: Rural Health Clinic Cost Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/14/2018
	Date Received in OIRA: 09/29/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved	04/30/2018
Responses	1,744	0	3,264
Time Burden (Hours)	95,920	0	163,200
Cost Burden (Dollars)	0	0	0

---

Abstract: The Form CMS-222-17 cost report is needed to determine program reimbursement and the amount of reasonable cost due to providers for furnishing medical services to Medicare beneficiaries.

---

Authorizing Statute(s): US Code: 42 USC 1395g Name of Law: Payment to Providers of services
   US Code: 42 USC 1395h Name of Law: Provisions relating to the administration of Part A
   US Code: 42 USC 1395i Name of Law: Payment of Benefits
   US Code: 42 USC 1395x Name of Law: Definitions of services, Institutions, etc
  

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:
	82 FR 33132	07/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 45589	09/29/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Rural Health Clinic Cost Report CMS-222-17	CMS-222-17	Rural Health Clinic Cost Report

---

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	1,744	3,264	0	0	-1,520	0
Annual Time Burden (Hours)	95,920	163,200	0	0	-67,280	0
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: A decrease in the number of respondents from 3,264 in 2014 to 1,744 in 2017. The significant decrease in respondents is a result of FQHCs no longer completing the Form CMS-222-17 as they now complete Form CMS-224-14. The 1,744 respondents in 2017 represent RHCs only.

---

Annual Cost to Federal Government: $2,660,000

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

---

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: 09/29/2017

---