Supporting Statement A

Supporting Statement A

Children’s Hospital Graduate Medical Education Payment Program

OMB Control No. 0915-0247

Revision

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

This is a request for approval from the Office of Management and Budget (OMB) for the revised Children’s Hospitals Graduate Medical Education (CHGME) Payment Program information collection request as submitted by the Health Resources and Services Administration (HRSA). The CHGME Payment Program’s current OMB approval will expire on February 29, 2020.

In 1999, the CHGME Payment Program was enacted by Public Law 106-129, and most recently amended by the Dr. Benjy Frances Brooks Children's Hospital GME Support Reauthorization Act of 2018 (P.L. 115-241). The purpose of this program is to fund freestanding children’s hospitals to support the training of pediatric and other residents in GME programs. The legislation indicates that eligible children’s hospitals receive payments for both direct medical education (DME) and indirect medical education (IME). Direct payments are designed to offset the expenses associated with operating approved graduate medical residency training programs and indirect payments are designed to compensate hospitals for expenses associated with the treatment of more severely ill patients and the additional costs relating to teaching residents in such programs. 

Section 340E(e)(3) of the Public Health Service Act states that the Secretary must determine any changes to the number of resident full-time equivalent (FTE) reported by a hospital in its (initial) application for CHGME Payment Program funding through a reconciliation application. The resident FTE counts reported by children’s hospitals in their reconciliation applications must be consistent with those reported by the CHGME fiscal intermediaries (FIs) to be accepted by the Department. Hospitals must report any changes to their resident FTE counts for those cost report years reflected in their initial applications. Prior to the end of each fiscal year (FY), the Department determines the final amount due to each participating children’s hospital based upon the reconciliation application cycle and pays any balance due or recoups any overpayment made to/from each children’s hospital. The form for determination of weighted and un-weighted resident FTE counts for the reconciliation application cycle is the same as the initial application cycle. If this data is not collected, HRSA will have no means to monitor grantees, verify grantee reporting, or determine grantee eligibility for CHGME funding.

A notice announcing implementation of the CHGME Payment Program was published in the Federal Register on June 19, 2000 (Vol. 65, No. 118, pages 37985-37992). Subsequent Federal Register notices were published which proposed and finalized CHGME Payment Program methodologies and processes. These included the following:

• 65 FR 37985 published June 19, 2000, Volume 65, Issue 118, pages 37985-37992

• 66 FR 12940 published March 1, 2001, Vol. 66, No. 41, pages 12940-12954

• 66 FR 37980 published July 20, 2001, Volume 66, Issue 140, pages 37980-37988

• 67 FR of 60241 published September 25, 2002, Volume 67, Issue 186, pages Volume 67, Issue 186

• 67 FR of 68879 published November 13, 2002, Volume 67, Issue 219, pages 68879-68880

• 68 FR of 60396 published October 22, 2003, Vol. 68, No. 204, pages 60396-60401

The application package includes: an introductory letter; overview of the CHGME Payment Program, information on the CHGME Payment Program application cycle and deadline requirements, application forms, hospital eligibility criteria, CHGME payment methodology, explanation of data needed by participating hospitals to complete the CHGME Payment Program application forms, information to assist hospitals in determining the number of resident FTEs that can be claimed for CHGME Payment Program payment, instructions for completing the application forms, and references.

In addition, the cover letter, conversation record, and exhibits required to be submitted by auditors in the FTE resident assessment final report are included.

2. Purpose and Use of Information Collection

HRSA uses the data to determine the amount of payments to each participating children’s hospital. Administration of the CHGME Payment Program relies on the reporting and audit of the number of resident FTEs in applicant children’s hospitals’ training programs to determine the amount of direct and indirect expense payments to participating children’s hospitals. Indirect expense payments are also derived from a formula that requires the reporting of case mix index information, the number of inpatient discharges, and the number of inpatient beds from participating children’s hospitals.

Hospitals are required to submit information in an initial application for CHGME Payment Program funding which includes the number of FTE residents trained by the hospital. Auditors must submit data on the number of full-time equivalent residents trained by the hospitals in an FTE resident assessment summary. An assessment of the hospital data ensures that appropriate Center for Medicare and Medicaid Services (CMS) regulations and CHGME program guidelines are followed in determining which residents are eligible to be claimed for funding. Audit results impact final payments made by the CHGME Payment Program to all eligible hospitals.

Before the end of the fiscal year, participating hospitals are also required to complete a reconciliation application for CHGME Payment Program funding furnishing final FTE numbers which reflect any changes to the number of residents reported by a hospital in its initial application. Additionally, the Government Performance and Results Act (GPRA) of 1993 requires the collection of performance data from participating children’s hospitals. These data are requested when the final number of resident FTEs is reported before the end of the fiscal year.

Based on feedback from current CHGME Payment Program grantees and a current CHGME resident FTE assessment contractor, this request now includes 30 separate forms. Previously, these five additional forms were combined. Specifically:

• HRSA 99-2 is now HRSA 99-2 (Initial) and HRSA 99-2 (Reconciliation);

• Application Cover Letter (Initial and Reconciliation) is now Application Cover Letter (Initial) and Application Cover Letter (Reconciliation)

• Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation) is now Exhibit 2 (Initial and Reconciliation) and Exhibit 2 (FTE Resident Assessment);

• Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation) is now Exhibit 3 (Initial and Reconciliation) and Exhibit 3 (FTE Resident Assessment); and

• Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation) is now Exhibit 4 (Initial and Reconciliation) and Exhibit 4 (FTE Resident Assessment).

Below is a discussion of each application form and accompanying guidance and instructions as well as the documentation required by the CHGME Fiscal Intermediaries (FIs) related to the audit of CHGME funded hospitals for which approval is requested.

These include forms for the following items:

1. the collection of data directly related to the administration of the CHGME Payment Program,

2. the reporting of performance measures as required by the GPRA of 1993, and

3. the collection of data directly related to the audit of the information submitted by CHGME Payment Program funded hospitals including for the reconciliation application and to be used for purposes of payment.

Application Forms for Use by CHGME Participating Hospitals

• Application Cover Letter (Initial and Reconciliation): This letter includes a brief description of the application submitted and an explanation of issues that may require attention, as well as a list of the documents included for review by CHGME Payment Program.

• HRSA 99 (Initial and Reconciliation): Demographic and Contact Information.

This form is used to identify the applicant hospital’s Medicare Provider Number,

Tax Identification Number, DUNS number, and the appropriate hospital liaisons for application processing and auditing purposes. This form is the initial part of each application.

• HRSA 99-1 (Initial): Determination of Weighted and Un-weighted Resident FTE Counts. This form must be completed as a component of the initial application. Information is requested on the hospital’s number of resident FTE unweighted and weighted counts for the current, previous, penultimate and base (1996) Medicate cost report (MCR) periods.

• HRSA 99-1 (Reconciliation): Determination of Weighted and Un-weighted Resident FTE Counts. This form must be completed as a component of the reconciliation application. Information is requested on the hospital’s number of resident FTE unweighted and weighted counts for the current, previous, penultimate and base (1996) MCR periods.

Per section 340E(c)(1) of the Public Health Service Act, payments for direct expenses relating to the hospital’s approved GME programs for a FY are equal to the product of (a) an updated national per resident amount for direct GME with wage adjustment and a labor share for each children’s hospital’s area applied to a standard wage-related portion, and (b) the average number of FTE residents as determined under Section 1886(h)(4) of the Social Security Act.

• HRSA 99-2 (Initial): Determination of IME Data Related to the Teaching of Residents. This form must be completed as a component of the initial application. Information is requested on the hospital’s number of inpatient days, number of inpatient discharges, number of available beds, case-mix index (CMI) and intern/resident to bed (IRB) ratio for the current, previous, penultimate and base (1996) MCR periods.

• HRSA 99-2 (Reconciliation): Determination of IME Data Related to the Teaching of Residents. This form must be completed as a component of the reconciliation application. Information is requested on the hospital’s number of inpatient days, number of inpatient discharges, number of available beds, CMI and IRB ratio for the current, previous, penultimate and base (1996) MCR periods.

Per section 340E(d) of the PHS Act, the Secretary must determine the amounts of IME payments by taking into account factors identified in section 340E(d)(2)(A) of the PHS Act --- variations in case mix, and the number of resident FTEs in the hospital’s approved GME training programs for a fiscal year.

• HRSA 99-4 (Reconciliation): Government Performance and Results Act (GPRA) Tables. This form is required for the collection of information per the GPRA of 1993, as well as §5504 of the Affordable Care Act of 2010 (ACA). It is requested before the end of the FY when the reconciliation application cycle occurs and the HRSA 99-1 and HRSA 99-2 are resubmitted reflecting changes, if any, to the resident FTE counts reported by the children’s hospitals in their initial applications for CHGME Payment Program funding.

• HRSA 99-5 (Initial and Reconciliation): Application Checklist. This form is a checklist developed in response to numerous requests by participating children’s hospitals to provide them with a checklist that they could use to ensure that their application for CHGME Payment Program funding was complete before submitting it to the CHGME Payment Program for consideration. The checklist identifies all required forms and supporting documentation, where appropriate, that an applicant children’s hospital must submit to the CHGME Payment Program to be considered for funding.

• CFO Form Letter (Initial and Reconciliation): This letter includes a brief description of the application resubmitted with corrections and an explanation of changes made as well as a list of the revised documents included for further review by CHGME Payment Program.

• Exhibit 2 (Initial and Reconciliation): Revised GME Affiliation Agreement(s) for an Aggregate Cap. Revised GME Affiliation Agreement(s) for an Aggregate Cap, if available, as well as the email confirmation receipt to CMS and proof of submission to the Medicare Administrative Contractor (MAC).

• Exhibit 3 (Initial and Reconciliation): Worksheet E-3, Part IV, if MCR was settled after hospital. Updated CMS Form 2552-10, Worksheet E-4 (formerly named Worksheet E-3, Part IV, and Worksheet E-3, Part VI), if required.

• Exhibit 4 (Initial and Reconciliation): Medicare Modernization Act (MMA) letter from CMS, must be included if hospital claims MMA. This letter is a copy of the letter sent to the provider by CMS informing the hospital of an increase and/or reduction in the resident FTE cap due to Section 422 of MMA, Section 5503 and 5506 of the ACA, if applicable.

FTE Assessment Forms Used by CHGME Fiscal Intermediaries

On October 22, 2003, the Secretary published a Federal Register Notice (Vol. 68, No. 204, page 60396) which established the Resident FTE Assessment Program to ensure this determination is made for resident FTE counts submitted by all children’s hospitals applying for CHGME Payment Program support. This determination is done by conducting a comprehensive assessment of the resident FTE counts claimed by children’s hospitals in their initial applications for CHGME Payment Program funding.

Beginning in FY 2003, the CHGME Payment Program contracted with its own FIs to assess the resident FTE counts submitted by participating children’s hospitals in their initial applications for CHGME Payment Program funding. This assessment of resident FTE counts is performed for all children’s hospitals regardless of the type of MCR filed. The following information, forms and supporting documentation are collected:

• HRSA 99-1 (Supplemental) (FTE Resident Assessment): Determination of Weighted and Un-weighted Resident FTE Counts. This form must be completed as a component of the FTE resident assessment. Information is requested on the hospital’s number of FTE resident unweighted and weighted counts for the current, previous, penultimate and base (1996) MCR periods.

• FTE Resident Assessment Cover Letter (FTE Resident Assessment): This letter includes a brief description of the audit that was performed and for which years, as well as a list of the documents included for review by the CHGME Payment Program.

• Conversation Record (FTE Resident Assessment): This is a summary of the actions taken during the audit, including the sampling technique used during reviews and details of which exhibits were submitted.

• Exhibit C (FTE Resident Assessment): CHGME FI Summary of Issues. This form details any issues encountered during the assessment that affected the audit process or the final resident FTE counts.

• Exhibit F (FTE Resident Assessment): CHGME FI Introductory Request Letter to Hospital. This letter introduces the CHGME FI to the hospital and is a formal request to the hospital for documentation to support resident FTEs claimed on the hospital’s initial application.

• Exhibit N (FTE Resident Assessment): Points for Future CHGME Auditors. This form facilitates continuity of communication from one CHGME FI to the next, and helps the Program and auditors track and follow up on any issues with each hospital in a timely manner.

• Exhibit O(1) (FTE Resident Assessment): CHGME FI Assessment Summary (Adjustment). This form lists the reasons for any increases or decreases in resident FTE counts reported by the hospital and briefly explain the reason the adjustment occurred.

• Exhibit O(2) (FTE Resident Assessment): CHGME HRSA 99-1. This form compiles the resident FTE counts reported by the hospital, filed CMS, and audited by the CHGME FI.

• Exhibit P (FTE Resident Assessment): CHGME FI Adjustment Letter to the Hospital. This letter provides a summary of the resident FTE assessment findings to the respective children’s hospitals.

• Exhibit P(2) (FTE Resident Assessment): CHGME Management Recommendation Letter to the Hospital. This letter is given to a hospital outlining certain conditions encountered during the audit and the recommended actions which to avoid similar CHGME Payment Program assessment findings during future audits.

• Exhibit S (FTE Resident Assessment): Final MAC Letter/ “Top Memorandum”. This letter is sent to notify the MAC of the completion of the resident FTE assessment for each respective hospital and to provide a summary report of the audit findings.

• Exhibit T (FTE Resident Assessment): Reopening Request Letter to MAC. This letter requests the resident FTE assessment finding be incorporated into the Medicare process, where applicable.

• Exhibit T(1) (FTE Resident Assessment): Reopening Request Letter to CHGME FI. This letter serves as a record for the CHGME FI of the request made to the MAC to incorporate resident FTE assessment findings into the Medicare process, where applicable.

• Exhibit 1 (FTE Resident Assessment): Summary of GME Affiliation Agreement(s). This work paper reconciles the GME Affiliation Agreement(s) and summarizes calculations that support final counts reflected in HRSA 99-1.

• Exhibit 2 (FTE Resident Assessment): Revised GME Affiliation Agreement(s) for an Aggregate Cap. Revised GME Affiliation Agreement(s) for an Aggregate Cap, if available, as well as the email confirmation receipt to CMS and proof of submission to the Medicare MAC.

• Exhibit 3 (FTE Resident Assessment): Worksheet E-3, Part IV, if MCR was settled after hospital. Updated CMS Form 2552-10, Worksheet E-4 (formerly named Worksheet E-3, Part IV, and Worksheet E-3, Part VI), if required.

• Exhibit 4 (FTE Resident Assessment): MMA letter from CMS, must be included if hospital claims MMA. This letter is a copy of the letter sent to the provider by CMS informing the hospital of an increase and/or reduction in the resident FTE cap due to Section 422 of MMA, Section 5503 and 5506 of the ACA, if applicable.

3. Use of Improved Information Technology and Burden Reduction

The HRSA forms are currently available electronically via the EHB to allow for the submission of the applications from the children’s hospitals. Review and assessment of the results are recorded electronically to increase efficiency and accuracy and to reduce costs.

4. Efforts to Identify Duplication and Use of Similar Information

Contract work was performed to specifically identify existing data sources and to determine their appropriateness for the administration of the CHGME Payment Program. The evaluation concluded that existing data are not currently collected by other entities for the reasons given below.

Prior to FY 2000, children’s hospitals varied in the completeness and accuracy of the resident FTE count data they furnished to the CMS data systems, and only some of the eligible children’s hospitals reported cost or resident FTE count data to CMS. The major issue for the CHGME Payment Program is the reporting of resident FTE data according to Medicare rules. The CHGME Payment Program requires the reporting of accurate past and current resident FTE count data under these rules, in order to make accurate payments for GME under the CHGME Payment Program.

Possible alternative data sources were reviewed (as described below) and found not to be satisfactory for the purpose of the CHGME Payment Program.

• The American Board of Pediatrics (ABP) collects FTE resident counts on most of the pediatric residents training in children’s hospitals. However, the weighting factors used to determine the counts are significantly different from the Medicare rules that must be used by the CHGME Payment Program. Furthermore, the ABP collects information by programs rather than by hospitals, and it does not collect counts on FTEs of other specialties. Moreover, ABP data are unlikely to include residents who rotate into the children’s hospital from programs in other hospitals.

• The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) obtains resident counts from some children’s hospitals for the purpose of reimbursement. However, the weighting rules and reporting periods differ from that of the Medicare and CHGME Payment Program.

• The Association of American Medical Colleges (AAMC) uses the AGME Track@ system, which supplants the resident count survey previously used by the American Medical Association and AAMC. The system requests resident numbers data from teaching hospitals and programs to be furnished between July and September each year. However, these numbers are not counted or weighted according to Medicare rules. Furthermore, the system does not produce accurate counts on a timely basis, as the counts can be modified as late as March of the following year.

Based upon the justification described in the three points above, the hospital may not want to certify such alternative counts as accurate, since they are not necessarily under the hospital’s control and could be difficult for the hospital to verify.

5. Impact on Small Businesses or Other Small Entities

This project does not have a significant impact on small business or other small entities. No small businesses will be involved in this study.

6. Consequences of Collecting the Information Less Frequently

The annual reporting of information is necessary to calculate payment amounts for the fiscal year. The number of resident FTEs, case mix, and utilization data are expected to change annually. The audit and annual reporting of corrections to previously reported information is necessary to complete the statutorily dictated reconciliation process. GPRA also requires the annual reporting of performance data.

6. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

This collection is consistent with the guidelines under 5 CFR 1320.5(d)(2). The request fully complies with the regulation.

6. Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A:

A 60-day Federal Register Notice was published in the Federal Register on July 11, 2019, vol. 84, No. 133; pp. 33079-80 (see attachment 1). There were no public comments received.

Section 8B:

In May and June 2019, the following CHGME Payment Program participants reviewed the CHGME materials for the burden estimate and for the clarity of instructions and forms. Based on their feedback, the burden hours for a number of forms was revised from the published 60-day FRN which resulted in an increase in burden hours from 8,018.40 hours to 8,197.80 hours:

1. Melissa Garrett

Manager, Financial Decision Support

Arkansas Children’s Hospital

1 Children’s Way, Slot 663

Little Rock, AR 72202

Phone: 501-364-2541

Fax: 501-364-3243

Email: [email protected]

2. Maulik Patel, MHA, MBA

Revenue Integrity Analyst

Driscoll Children’s Hospital

3533 S. Alameda Street

Corpus Christi, TX 78411

Phone: 361-694-4988

Email: [email protected]

3. Janet McCarthy, CPA

Manager, Cost Reporting and Provider Enrollment

Children’s Hospitals and Clinics of Minnesota

Revenue Manager Dept.

Internal Mail Stop 35-121A

2919 Centre Pointe Drive

Roseville, MN 55113

Phone: 651-855-2312
Fax: 651-855-2310

Email: [email protected]

4. Jennifer Tryder

Program Director

Integrity Management Services, Inc.

5911 Kingstowne Village Parkway, Suite 210

Alexandria, VA 22315

Office/Mobile: 978.979.5831

Email: [email protected]

6. Explanation of any Payment/Gift to Respondents

Respondents will not receive any payments or gifts.

6. Assurance of Confidentiality Provided to Respondents

No personal identifiers will be collected.

6. Justification for Sensitive Questions

There are no questions of a sensitive nature.

12. Estimates of Annualized Hour and Cost Burden

The estimated burden hours are reflected in the following table:

12A. Estimated Annualized Burden Hours

Form Name	Number of Respondents	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Application Cover Letter (Initial)	60	1	60	0.33	19.8
Application Cover Letter (Reconciliation)	60	1	60	2.5	150
HRSA 99 (Initial and Reconciliation)	60	2	120	0.33	39.6
HRSA 99-1 (Initial)	60	1	60	26.5	1,590
HRSA 99-1 (Reconciliation)	60	1	60	6.5	390
HRSA 99-1 (Supplemental) (FTE Resident Assessment)	30	2	60	3.67	220.2
HRSA 99-2 (Initial)	60	1	60	9.67	580.2
HRSA 99-2 (Reconciliation)	60	1	60	2.84	170.4
HRSA 99-4 (Reconciliation)	60	1	60	12.5	750
HRSA 99-5 (Initial and Reconciliation)	60	2	120	0.33	39.6
CFO Form Letter (Initial and Reconciliation)	60	2	120	0.33	39.6
Exhibit 2 (Initial and Reconciliation)	60	2	120	0.33	39.6
Exhibit 3 (Initial and Reconciliation)	60	2	120	1.83	219.6
Exhibit 4 (Initial and Reconciliation)	60	2	120	0.33	39.6
FTE Resident Assessment Cover Letter (FTE Resident Assessment)	30	2	60	0.25	15
Conversation Record (FTE Resident Assessment)	30	2	60	1	60
Exhibit C (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit F (FTE Resident Assessment)	30	2	60	1.5	90
Exhibit N (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit O(1) (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit O(2) (FTE Resident Assessment)	30	2	60	30	1,800
Exhibit P (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit P(2) (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit S (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit T (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit T(1) (FTE Resident Assessment)	30	2	60	.25	15
Exhibit 1 (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit 2 (FTE Resident Assessment)	30	2	60	0.33	19.8
Exhibit 3 (FTE Resident Assessment)	30	2	60	3.5	210
Exhibit 4 (FTE Resident Assessment)	30	2	60	0.33	19.8
Total	*90	-	*90	-	8,197.80

* The total is 90 because the same hospitals and auditors are completing the forms.

Basis for estimates:

Hospital Respondents

• Application Cover Letter (Initial): Each participating hospital must complete and submit a cover letter with the submission of the application to the CHGME Payment Program. The number of respondents (60) submitting the letter is based on responses from hospitals which complete the CHGME application annually.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 application x 0.33 hours per response = 19.8 total burden hours).

A total of 19.8 burden hours (1 responses per hospital x 19.8) for initial application.

• Application Cover Letter (Reconciliation): Each participating hospital must complete and submit a cover letter with the submission of the application to the CHGME Payment Program. The number of respondents (60) submitting the letter is based on responses from hospitals which complete the CHGME application annually.

The hours per response (2.5 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 2.5 hours per response = 150 total burden hours).

A total of 150 burden hours (1 responses per hospital x 2.5) for initial and reconciliation application.

• HRSA 99 (Initial and Reconciliation): Demographic and Contact Information. Each participating hospital must complete and submit a HRSA 99 to apply for annual funding under the CHGME Payment Program. The number of respondents (60) completing the form is based on responses from hospitals which complete the HRSA 99 semiannually.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 initial application x 0.33 hours per response = 19.8 total burden hours).

The hours per response (0.33 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 0.33 hours per response = 19.8 total burden hours).

A total of 39.6 burden hours (2 responses per hospital x 19.8) for initial and reconciliation application.

• HRSA 99-1 (Initial) and HRSA 99-1 (Reconciliation): Determination of Weighted and Un-weighted Resident FTE Counts. Each participating hospital must complete and submit a HRSA 99-1 to apply for annual funding under the CHGME Payment Program. The number of respondents (60) completing the form is based on responses from hospitals which complete the HRSA 99-1 semiannually.

The hours per response (26.5 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 initial application x 26.5 hours per response = 1,590 total burden hours).

The hours per response (6.5 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 6.5 hours per response = 390 total burden hours).

• HRSA 99-2 (Initial) and HRSA 99-2 (Reconciliation): Determination of Indirect Medical Education Data Related to the Teaching of Residents. Each participating hospital must complete and submit a HRSA 99-2 to apply for annual funding under the CHGME Payment Program. The number of respondents (60) completing the form is based on responses from hospitals which complete the HRSA 99-2 semiannually.

The hours per response (9.67 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 initial application x 9.67 hours per response = 580.2 total burden hours).

The hours per response (2.84 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 2.84 hours per response = 170.4 total burden hours).

• HRSA 99-4 (Reconciliation): Government Performance and Results Act Tables. Under the GPRA of 1993 and as part of the annual application requirements, each participating hospital must complete and submit a HRSA 99-4. The number of respondents (60) completing the form is based on responses from hospitals which complete the HRSA 99-4 annually.

The hours per response (12.5 hours) are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 reconciliation application x 12.5 hours per response = 750 total burden hours).

• HRSA 99-5 (Initial and Reconciliation): Application Checklist. Each participating hospital must complete and submit a HRSA 99-5 to apply for annual funding under the CHGME Payment Program. The number of respondents (60) completing the form is based on responses from hospitals which complete the HRSA 99-5 semiannually.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 initial application x 0.33 hours per response = 19.8 total burden hours).

The hours per response (0.33 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 0.33 hours per response = 19.8 total burden hours).

A total of 39.6 burden hours (2 responses per hospital x 19.8) for initial and reconciliation application.

• CFO Form Letter (Initial and Reconciliation). Each participating hospital must complete and submit a CFO Form Letter with the revised applications submitted to the CHGME Payment Program for all audited hospitals. The number of respondents (60) submitting the letter is based on responses from hospitals which complete the CHGME application semiannually.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with hospitals (60 hospitals x 1 application x 0.33 hours per response = 19.8 total burden hours).

The hours per response (0.33 hours) for the reconciliation application are based upon program experience working with the hospitals and discussions with the hospitals (60 hospitals x 1 reconciliation application x 0.33 hours per response = 19.8 total burden hours).

A total of 39.6 burden hours (2 responses per hospital x 19.8) for initial and reconciliation application.

• Exhibit 2 (Initial and Reconciliation): Revised GME Affiliation Agreement(s) for an Aggregate Cap. Each participating hospital must submit a current copy of the hospital’s affiliation agreement(s) for the current year, prior year, penultimate years and base year with the CHGME initial and reconciliation application. The number of respondents (60) completing the form is based on the number of children’s hospitals participating in the CHGME Payment Program.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with the 60 hospitals x 0.33 hours x 2 responses = 39.6 total burden hours).

• Exhibit 3 (Initial and Reconciliation): Worksheet E-4 (formally known as Worksheet E-3, Part IV). Each participating hospital must submit a copy of the Worksheet E-4 (formally known as Worksheet E-3, Part IV) for the current year, prior year, penultimate years and base year with the CHGME initial and reconciliation application. The number of respondents (60) completing the form is based on the number of children’s hospitals participating in the CHGME Payment Program.

The hours per response (1.83 hours) for an initial application are based upon program experience working with the hospitals and discussion with the 60 hospitals x 1.83 hours x 2 responses = 219.6 total burden hours).

• Exhibit 4 (Initial and Reconciliation): MMA letter from CMS, must be included if hospital claims MMA. Each participating hospital must submit a current copy of the MMA letter from CMS, Section 5503 letter from CMS and other correspondence from CMS that affect the resident FTE counts reported with the CHGME initial and reconciliation application. The number of respondents (60) completing the form is based on the number of children’s hospitals participating in the CHGME Payment Program.

The hours per response (0.33 hours) for an initial application are based upon program experience working with the hospitals and discussion with the 60 hospitals x 0.33 hours x 2 responses = 39.6 total burden hours).

Auditor Respondents

• HRSA 99-1 (Supplemental) (FTE Resident Assessment): Determination of Weighted and Un-weighted Resident FTE Counts. Each auditor must complete and submit a HRSA 99-1 with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.67 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 FTE resident assessments x 3.67 hours per response = 220.2 total burden hours).

A total of 220.2 burden hours (2 responses per auditor) for the FTE resident assessment.

• FTE Resident Assessment Cover Letter (FTE Resident Assessment): Each auditor must complete and submit a cover letter with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (0.25 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 0.25 hours per response = 15 total burden hours).

• Conversation Record (FTE Resident Assessment): Each assigned auditor must complete and submit a conversation record with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (1.0 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 1.0 hours per response = 60 total burden hours).

• Exhibit C (FTE Resident Assessment): CHGME FI Summary of Issues. Each auditor must complete and submit a summary of issues with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit F (FTE Resident Assessment): CHGME FI Introductory Request Letter to Hospital. Each auditor must include a copy of the introductory request letter to the hospital with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (1.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 1.5 hours per response = 90 total burden hours).

• Exhibit N (FTE Resident Assessment): Points for Future CHGME Auditors. Each auditor must complete and submit a document which includes points for future CHGME auditors with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.50 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.50 hours per response = 210 total burden hours).

• Exhibit O(1) (FTE Resident Assessment): CHGME FI Assessment Summary (Adjustment). Each auditor must complete and submit an Exhibit O(1) with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.50 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.50 hours per response = 210 total burden hours).

• Exhibit O(2) (FTE Resident Assessment): CHGME HRSA 99-1. Each auditor must complete and submit an Exhibit O(2) with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (30 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 30 hours per response = 1,800 total burden hours).

• Exhibit P (FTE Resident Assessment): CHGME FI Adjustment Letter to the Hospital. Each auditor must include a copy of the CHGME FI adjustment letter to the hospital with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit P(2) (FTE Resident Assessment): CHGME Management Recommendation Letter to the Hospital. Each auditor must include a copy of the CHGME management recommendation letter to the hospital with the resident FTE assessment reported to the CHGME Payment Program for audited hospitals (if applicable). The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit S (FTE Resident Assessment): Final Medicare Administrative Contact (MAC) Letter/ “Top Memorandum”. Each auditor must include a copy of the “Top Memorandum” sent to the MAC with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit T (FTE Resident Assessment): Reopening Request Letter to MAC. Each auditor must include a copy of the reopening request letter to the MAC with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit T(1) (FTE Resident Assessment): Reopening Request Letter to CHGME FI. Each auditor must include a copy of the Reopening Request Letter to CHGME FI with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (0.25 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 0.25 hours per response = 15 total burden hours).

• Exhibit 1 (FTE Resident Assessment): Summary of GME Affiliation Agreement(s). Each auditor must complete and submit a current copy of the summary of GME affiliation agreement (s) with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.5 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 resident FTE Assessment x 3.5 hours per response = 210 total burden hours).

• Exhibit 2 (FTE Resident Assessment): Revised GME Affiliation Agreement(s) for an Aggregate Cap. Each auditor must submit a current copy of the hospital’s affiliation agreement(s) for the current year, prior year, penultimate years and base year with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (0.33 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 FTE resident assessments x 0.33 hours per response = 19.8 total burden hours).

• Exhibit 3 (FTE Resident Assessment): Worksheet E-4 (formally known as Worksheet E-3, Part IV). Each auditor must submit a copy of the Worksheet E-4 (formally known as Worksheet E-3, Part IV) for the current year, prior year, penultimate years and base year with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (3.50 hours) are based upon program experience with the FTE resident assessment and discussion with the auditors (30 auditors x 2 FTE resident assessments x 3.50 hours per response = 210 total burden hours).

• Exhibit 4 (FTE Resident Assessment): MMA letter from CMS, must be included if hospital claims MMA - Each auditor must submit a current copy of the MMA letter from CMS, Section 5503 letter from CMS and other correspondence from CMS that affect the resident FTE counts reported with the resident FTE assessment reported to the CHGME Payment Program for all audited hospitals. The number of respondents (30) completing the form is based on the number of CHGME fiscal intermediaries assigned to perform audits for the children’s hospitals receiving funding.

The hours per response (0.33 hours) for an initial application are based upon program experience with the FTE resident assessment and discussion with the auditors (30 hospitals and auditors x 2 FTE resident assessment x 0.33 hours per response = 19.8 total burden hours).

12B. Estimated Annualized Burden Costs

Type of Respondent	Number of Responses per Respondent	Total Burden Hours	Wage Rate ($/hr.)	Total Hour Costs ($)
Hospital	1	19.8	$141.18	$2,795.36
Hospital	1	150	$141.18	$21,177
Hospital	2	39.6	$141.18	$5,590.73
Hospital	1	1,590	$141.18	$224,476.30
Hospital	1	390	$141.18	$55,060.20
Hospital	1	580.2	$141.18	$81,912.64
Hospital	1	170.4	$141.18	$24,057.07
Hospital	1	750	$141.18	$105,885
Hospital	2	39.6	$141.18	$5,590.73
Hospital	2	39.6	$141.18	$5,590.73
Hospital	2	39.6	$141.18	$5,590.73
Hospital	2	219.6	$141.18	$31,003.13
Hospital	2	39.6	$141.18	$5,590.73
Total	-	4,068	-	$574,320.35

Source: https://www.bls.gov/oes/current/oes113031.htm

Type of Respondent	Number of Responses per Respondent	Total Burden Hours	Wage Rate ($/hr.)	Total Hour Costs ($)
Auditor	2	220.2	$118.12	$26,010.02
Auditor	2	15	$118.12	$1,771.80
Auditor	2	60	$118.12	$7,087.20
Auditor	2	210	$118.12	$24,805.20
Auditor	2	90	$118.12	$10,630.80
Auditor	2	210	$118.12	$24,805.20
Auditor	2	210	$118.12	$24,805.20
Auditor	2	1,800	$118.12	$212,616
Auditor	2	210	$118.12	$24,805.20
Auditor	2	210	$118.12	$24,805.20
Auditor	2	210	$118.12	$24,805.20
Auditor	2	210	$118.12	$24,805.20
Auditor	2	15	$118.12	$1,771.80
Auditor	2	210	$118.12	$24,805.20
Auditor	2	19.8	$118.12	$2,338.78
Auditor	2	210	$118.12	$24,805.20
Auditor	2	19.8	$118.12	$2,338.78
Total	-	4,129.80	-	$487,811.98

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

Capital costs and start-up costs are minimal since implementation of the program occurred in FY 2000. There are no operational or maintenance costs. Other than their time, there is no cost to respondents.

13. Annualized Cost to Federal Government

The revised total cost to the Federal Government for this information collection includes the costs associated with contracted auditors are estimated to be $243,905.99 as follows:

Source: https://www.bls.gov/oes/current/oes132011.htm

The cost to the Federal Government is relative to the review and audit of two applications (1 initial application and 1 reconciliation application) and one FTE assessment per hospital.

The revised total costs to the Federal Government for this information collection are estimated to be $22,281.60 as follows:

Federal Staff Time

• Review incoming initial application and reconciliation application from the children’s hospitals and resident FTE assessment final reports from auditors to (1) ensure application packages are complete and (2) include all required forms, signatures, and supporting documentation.

[GS13/1 (includes locality payment for Washington DC metropolitan area) @ $47.52/hour X 60 applications/assessments X 3 reviews X 15 minutes (.25 hours) per application.]

$2,138.40

• Audit complete initial and reconciliation applications from the children’s hospitals and resident FTE assessment final reports from CHGME fiscal intermediaries to ensure that (1) the forms were completed in accordance with stated guidance and instructions and (2) data reported is logical and consistent with supporting documentation and information previously reported to the CHGME Payment Program. Communicate with hospitals and CHGME FIs, as needed, to resolve discrepancies.

[GS13/1 @ $47.52/hour X 60 applications/assessments X 3 reviews X 2 hours per application]

$17,107.20

• Notification of award to hospitals, assurance of invoice for payment and other required documentation, and rechecking of appropriate payment amount for DME and IME payments to hospitals:

[GS13/1 @ $47.52/hour X 60 applications/assessments X 2 reviews X 15 minutes (.25 hours) per application.]

$1,425.60

• Fiscal services management, staff, and computer support.

$6.71/obligation X 60 hospitals X 4 obligations/transactions. This figure does not include additional obligations/transactions that may occur if the Department/Agency makes payments to participating children’s hospitals while operating under a continuing resolution. In FY2018, the Department made monthly payments to each participating hospital in four (4) obligations/transactions.

This cost has decreased due to the continued streamlining of the payment process with the utilization of the Payment Management System (PMS).

$ 1,610.40

Note: CHGME Payment Program payments for both direct and indirect graduate medical education payments were made available through the Grant Payment Management System (PMS) as of July 2009. CHGME DME and IME payments were previously wired electronically to a bank account specified by the institution.  The PMS is a centralized grants payment and cash management system, operated by the HHS Program Support Center (PSC), Division of Payment Management (DPM). The PMS accomplishes all payment-related activities for HHS grants from the time of award through closeout. Under this system, recipients (children’s hospitals participating in the CHGME Payment Program) are responsible for drawing down their monthly allotted payments and complying with all rules, regulations, and policies associated with the PMS. 

Children’s hospitals have to draw down their own monthly funds following terms and conditions specified by a Notice of Grant Award (NoA).  The NoA replaced the notice of award letters and vouchers that were previously sent by the program. These NoA’s are sent via email to contacts at the facilities that have the authority to draw down the monthly funds.  The NoA's are sent by staff in the Division of Grants Management and not by CHGME Payment Program staff.

13. Explanation for Program Changes or Adjustments

The current burden inventory is 6161 hours and this request is for 8197.80 hours.

The burden inventory for 2016 was entered incorrectly, the burden estimate should have been 8,164.80 hours. The burden estimate will increase 33 hours for this request.

13. Plans for Tabulation, Publication, and Project Time Schedule

HRSA currently publishes performance highlights and accomplishments of the CHGME Payment Programs on our website at https://bhw.hrsa.gov/health-workforce-analysis/research/program-highlights. Additional publication of information and data are not currently planned, however HRSA may want to publish additional aggregate highlights from our CHGME hospitals in the future. Data will also be analyzed for internal administrative purposes and for tracking the performance indicators.

13. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and Expiration date will be displayed on every page of every form/instrument.

13. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.