Submissions of 1135 Waiver Request Automated Process (CMS-10752)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10752 Acute Hospital Care at Home	Form and Instruction	New	Repair queued
Form CMS-10752 1135 Waiver Request Automated Process	Form and Instruction	Modified	Repair queued
CMS-10752 Response to Public Comments.docx	Supplementary Document	Uploaded 2021-02-16	Repair queued
CMS-10752 1135 Waiver Web Form Emergency Justification 9-30-20.pdf	Supplementary Document	Uploaded 2020-10-08	Repair queued
CMS 10752 Supporting Statement final 2-19-21.docx	Supporting Statement A	Uploaded 2021-02-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245795	Acute Hospital Care at Home	Form and Instruction	New
243968	1135 Waiver Request Automated Process	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1384	ICR Reference No: 202102-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202010-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Submissions of 1135 Waiver Request Automated Process (CMS-10752)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/19/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2021
Responses	4,020	3,000
Time Burden (Hours)	5,629	3,000
Cost Burden (Dollars)	0	0

---

Abstract: Waivers under Section 1135 of the Social Security Act (the Act) and certain flexibilities allow the CMS to relax certain requirements, known as the Conditions of Participation (CoPs) or Conditions of Coverage to promote the health and safety of beneficiaries. Under Section 1135 of the Act, the Secretary may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure that sufficient health care services are available to meet the needs of individuals enrolled in Social Security Act programs in the emergency area and time periods. These waivers ensure that providers who provide such services in good faith can be reimbursed and exempted from sanctions. During emergencies, such as the current COVID-19 public health emergency (PHE), CMS must be able to apply program waivers and flexibilities under section 1135 of the Social Security Act, in a timely manner to respond quickly to unfolding events. In a disaster or emergency, waivers and flexibilities assist health care providers/suppliers in providing timely healthcare and services to people who have been affected and enables states, Federal districts, and U.S. territories to ensure Medicare and/or Medicaid beneficiaries have continued access to care. During disasters and emergencies, it is not uncommon to evacuate Medicare-participating facilities and relocate patients/residents to other provider settings or across state lines, especially, during hurricane and tornado events. CMS must collect relevant information for which a provider is requesting a waiver or flexibility to make proper decisions about approving or denying such requests. Collection of this data aids in the prevention of gaps in access to care and services before, during, and after an emergency. CMS must also respond to inquiries related to a PHE from providers and beneficiaries. CMS is not collecting information from these inquiries; we are merely responding to them.

---

Authorizing Statute(s): US Code: 42 USC 1135 Name of Law: Social Security Act
   US Code: 42 USC 1812(f) Name of Law: Social Security Act
   US Code: 42 USC 1320b-5 Name of Law: Social Security Act
  

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:
	85 FR 66990	10/21/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 10282	02/19/2021
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
1135 Waiver Request Automated Process	CMS-10752, CMS-10752	Waiver Inquiry Form ,   Helath Care Facility Status Collection Form
Acute Hospital Care at Home	CMS-10752	Acute Hospital at Home

---

ICR Summary of Burden

table that charts list 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	4,020	3,000	0	1,020	0	0
Annual Time Burden (Hours)	5,629	3,000	0	2,629	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Subsequent to the Emergency information collection request, we are revising the package to include a second form, Healthcare Facility Status Workflow, which is for operational status information which will be used to assist providers in delivering critical care to beneficiaries during emergencies. The burden hours increased by 591 hours due to this additional form. We are also correcting a grammatical error from the previous submission. The total burden hours should have been 3,139 instead of 3,000. There were burden hours added as well which brought the total to 3,730. In addition to the changes mentioned earlier in this section, we are also adding 299 hours of burden to account for a violation of the Paperwork Reduction Act for the Acute Hospital Care at Home waiver initiative. We have provided burden for the violation as well as burden estimates for future efforts related to waiver which equate to 1,600 hours. The total burden hours for this ICR are 5,629 (3,730 + 299 + 1,600).

---

Annual Cost to Federal Government: $1,616,528

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? Yes

---

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: 02/19/2021

---