Independent Renal Dialysis Facility Cost Report (CMS-265-11)

ICR 202205-0938-001

OMB: 0938-0236

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2022-05-05
Supplementary Document
2022-05-03
IC Document Collections
IC ID
Document
Title
Status
7893 Modified
ICR Details
0938-0236 202205-0938-001
Received in OIRA 201709-0938-009
HHS/CMS CM-FFS
Independent Renal Dialysis Facility Cost Report (CMS-265-11)
Reinstatement with change of a previously approved collection   No
Regular 05/05/2022
  Requested Previously Approved
36 Months From Approved
7,492 0
494,472 0
0 0

CMS requires the Form CMS-265-11 to determine an ESRD facility’s reasonable costs incurred in furnishing medical services to Medicare beneficiaries. ESRD facilities paid under the ESRD prospective payment system (PPS) may receive reimbursement in addition to the ESRD PPS payment for Medicare reimbursable bad debts. CMS uses the Form 265-11 for annual rate setting; payment refinement activities, including developing a ESRD market basket; and Medicare Trust Fund projections; and to support program operations. Additionally, the Medicare Payment Advisory Commission (MedPAC) uses the cost report data to calculate Medicare margins (a measure of the relationship between Medicare’s payments and providers’ Medicare costs) and analyze data to formulate Medicare Program recommendations to Congress.

PL: Pub.L. 110 - 275 153 Name of Law: Medicare Improvements for Patients and Providers Act
   US Code: 42 USC 1395g Name of Law: Payment of Providers of Services
  
None

Not associated with rulemaking

  87 FR 9627 02/22/2022
87 FR 26760 05/05/2022
No

1
IC Title Form No. Form Name
Renal Dialysis Facility Cost Report CMS-265-11 Renal Dialysis Facility Cost Report

  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 7,492 0 0 671 0 6,821
Annual Time Burden (Hours) 494,472 0 0 51,107 0 443,365
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
An increase in the number of respondents by 671 (from 6,821 in 2017 to 7,492 in 2021), the net result of new ESRD facilities certified to participate in the Medicare program and existing ESRD facilities terminated from the Medicare program; An increase in the burden hours from 65 in 2017 to 66 in 2021 due to the proposed Worksheet A-7.

$30,013,098
No
    No
    No
No
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/05/2022


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