Home Health Agency Cost Report and Supporting Regulations (CMS-1728-20)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1728-20 Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106	Form	Modified	Available
CMS-1728-20.Response to 30-day comments (5-20-20).docx	Supplementary Document	Uploaded 2020-05-27	Available
CMS-1728-20 Crosswalk (revised based on 30-day comments)-5-26-20.docx	Supplementary Document	Uploaded 2020-05-27	Available
CMS-1728-19_ResponseTo60-dayComments.pdf	Supplementary Document	Uploaded 2020-02-26	Available
CMS-1728-19_Crosswalk.pdf	Supplementary Document	Uploaded 2020-02-26	Available
CMS-1728-20.Supporting Statement Part A (5-20-20).docx	Supporting Statement A	Uploaded 2020-05-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7766	Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106	Form	Modified

ICR Details

OMB Control No: 0938-0022	ICR Reference No: 202002-0938-013
Status: Active	Previous ICR Reference No: 201602-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-1728-19
Title: Home Health Agency Cost Report and Supporting Regulations (CMS-1728-20)
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: 06/04/2020
	Date Received in OIRA: 02/26/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved
Responses	10,139	0	0
Time Burden (Hours)	1,977,105	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Form CMS-1728-20 is the form used by Home Health Agencies to report their health care costs to determine the amount of reimbursement for services furnished to Medicare beneficiaries.

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Authorizing Statute(s): US Code: 42 USC 1395g Name of Law: null
   Statute at Large: 18 Stat. 1815 Name of Statute: null
   Statute at Large: 18 Stat. 1861 Name of Statute: 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:
	84 FR 15616	04/16/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 10442	02/24/2020
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
Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106	CMS-1728-20	HHA Cost 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	10,139	0	0	0	-578	10,717
Annual Time Burden (Hours)	1,977,105	0	0	-324,448	-131,206	2,432,759
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a reinstatement with change of a previously approved collection. The burden has changed since the last submission as a result of wage data being updated, the number of respondents decreasing, and the removal of obsolete data elements and/or worksheets from the collection.

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Annual Cost to Federal Government: $6,487,852

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? No

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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: 02/26/2020

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