Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

Forms and Documents

Document	Type	Status	Availability
Form CMS-287-21 Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	Form	Modified	Repair queued
R1P248i.pdf	Supplementary Document	Uploaded 2020-12-24	Repair queued
R1P248f.xlsx	Supplementary Document	Uploaded 2020-12-24	Repair queued
CMS-287-21_Crosswalk_508.pdf	Supplementary Document	Uploaded 2020-12-24	Repair queued
CMS-287-21_Responses_to_60day_comments.pdf	Supplementary Document	Uploaded 2020-12-24	Repair queued
CMS-287-21_Supporting_Statement_Part_A.docx	Supporting Statement A	Uploaded 2020-12-24	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
7881	Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	Form	Modified

ICR Details

OMB Control No: 0938-0202	ICR Reference No: 202012-0938-018
Status: Received in OIRA	Previous ICR Reference No: 201410-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/24/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,626	0
Time Burden (Hours)	757,716	0
Cost Burden (Dollars)	0	0

---

Abstract: The Form CMS-287-05 is filed annually by Chain Home Offices to report the information necessary for the determination of Medicare reimbursement to components of chain organizations.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1833 Name of Statute: null
   Statute at Large: 18 Stat. 1815 Name of Statute: null
  

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:
	84 FR 48145	09/12/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 76079	11/27/2020
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	CMS-287-21	Home Office Cost Statement

---

ICR Summary of Burden

	Total Request	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	1,626	0	0	0	-60	1,686
Annual Time Burden (Hours)	757,716	0	0	0	-27,960	785,676
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 burden has been adjusted downward to account for a decrease in the number of respondents. The per task burden remains unchanged.

---

Annual Cost to Federal Government: $7,745,451

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

---

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: 12/24/2020

---