CMS-417 Supporting Statement Part A 5-15-18

SUPPORTING STATEMENT FOR THE

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

A. BACKGROUND

This is a request for a reinstatement of approval for the CMS-417, the Hospice Request for Certification in the Medicare Program which was previously approved under OMB control number 0938-0313. The approval for OMB control number 0938-0313 lapsed due to administrative issues.

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.

Section 1861(dd) of the Social Security Act (the Act) defines Hospice Care and Hospice Program with respect to the Medicare Hospice Benefit. The regulations at 42 CFR 418 set forth the Health and Safety Conditions of Participation (CoPs) that all Hospices must meet to participate in Medicare.

The Secretary has authorized States through contracts to conduct surveys of hospices to determine the hospices’ compliance with these requirements.

2. Information Users

This certification form (CMS-417) is used in the initial stages of the survey process to gather and record minimum identification information into the Survey and Certification technology system (currently the Automated Survey Processing Environment [ASPEN]) in the State and at the central and regional offices of the Centers for Medicare and Medicaid Services.

Ultimately, the information from this form is used by CMS in making initial certification and for 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.

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. At the time of the recertification, the form is 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 information on the CMS-417 is entered into the Survey and Certification technology system (currently the Automated Survey Processing Environment [ASPEN]), and it 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 a hospice must meet 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.

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.

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 from 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. The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 (P.L. 113-185) mandates that all Medicare certified hospices be surveyed every three years beginning April 6, 2015, and ending September 30, 2025.

7. Special Circumstances

_{There are no special circumstances.}

_{8. Federal Register Notice/Outside Consultation}

The 60-day Federal Register notice published on August 8, 2017 (82 FR 37097). There were no public comments.

The 30-day Federal Register notice published on October 26, 2017 (82 FR 49611).

9. Payment Gift to Respondent

There are no payments or gifts made to a respondent for completion of this data collection.  The payments are made for services rendered to our beneficiaries.  These reports collect the data for the costs and payments made to a provider. 

If they fail to submit these reports, there are penalties that are applied.  The penalty is the suspension of claims payments until a report is submitted. Once the report is submitted the payments for claims are released.  If they file the report timely there are no payment or gifts and no interruption in the claims payments.

_{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)}

Form CMS-417 is completed by a hospice when it first applies for certification to participate in the Medicare program (i.e., at initial certification) and thereafter at recertification during an unannounced survey by the State Survey Agency. Based on the simplicity of the form and its past usage, we estimate that it takes approximately 15 minutes (0.25 hour) to complete. The required information should be readily available to the hospice, thus no research or analysis would be needed.

In Calendar Year 2016, there were 2,554 non-accredited hospices nationwide. Under the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 (P.L. 113-185), all Medicare certified hospices must be surveyed every three years beginning April 6, 2015, and ending September 30, 2025. Since one third of 2,554 hospices is 851, we use this figure to estimate the burden going forward.

_{We estimate the annual hourly burden of form CMS-417 to be 213 hours/year.}

851 Hospices completing the form

x 0.25 Hours to complete form

_{213 Hours (annual) of burden for completion of form}

Typically, the hospice administrator is the responsible signatory. Using figures from the most current data from the Bureau of Labor Statistics (BLS), we estimate the average hourly salary of the hospice administrator (11-9111, Medical and Health Services Managers) to be $91.60 per hour. (See https://www.bls.gov/oes/current/oes119111.htm.) We reached this estimate by starting with the BLS hourly mean wage for managers in Home Health Care Services ($45.80 per hour) and then doubling it (to $91.60 per hour), to account for benefits and other overhead. Our previous estimate assumed a rate of $68 per hour; this previous figure was derived from BLS data and referenced in the FY 2015 Hospice Wage Index and Payment Rate Update.

213 hours/year x $91.60/hour = $19,511 / year

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}

_{Recently, Congress required that hospices must be surveyed every three years. These requirements came from} the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 (P.L. 113-185), effective date April 6, 2015. We believe these requirements provide for a more reliable and appropriate way to estimate the number of hospices impacted. In this document, we estimate that one third of the 2,554 non-accredited hospices (CY 2016) will be impacted, or 851 non-accredited hospices. Previously, we estimated that 1,168 hospices would complete the form; we reached this estimate by starting with the number of standard surveys in FY 2013 (847) and then adding 321 initial surveys. However, as initial surveys are a subset of standard surveys, a more accurate estimate need not include this subset. Thus in our current estimate, the burden figures have changed. The estimated hourly burden has decreased from 292 hours to 213 hours per year.

The annual cost burden described in our current estimate has decreased slightly from the previously approved package, from $19,846 to $19,511. This cost decrease reflects the decrease in the estimated number of hospices. We otherwise note the increase in the current estimated hourly rate from $68.00/hour to $91.60/hour, as explained above at Item 12.

16. Publication and Tabulation Dates

_{There are no publication and tabulation dates.}

_{17. Expiration Date}

_{CMS will display the expiration date on the form.}

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.

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