Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators (CMS-10821)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10821 Supplement to Form CMS-2552-10	Form	Modified	Available
Form CMS-10821 Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Form	Modified	Repair queued
CMS-10821.Supporting Statement Part A (final rule).docx	Supporting Statement A	Uploaded 2022-12-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
254942	Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Form	Modified	Supplement to Form CMS-2552-10
254942	Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Form	Modified
254942	Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	Instruction	Modified

ICR Details

OMB Control No: 0938-1425	ICR Reference No: 202212-0938-003
Status: Historical Active	Previous ICR Reference No: 202207-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators (CMS-10821)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/02/2022
Terms of Clearance: Prior to the re-submission of the information collection Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators (CMS-10821)(0938-1425), the agency will evaluate its respondents experience and burden as well as the utility of the data collection. This assessment will inform and be integrated in the agency’s next revision or extension of this information collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2025	36 Months From Approved
Responses	4,662	0	0
Time Burden (Hours)	2,331	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Supplemental to Form CMS-2552-10 cost report is needed to determine the payment adjustment for wholly domestically-made NIOSH-approved surgical N95 respirators purchased by an 1886(d) hospital or a hospital paid for outpatient services under the hospital outpatient prospective payment system for cost reporting periods beginning on or after January 1, 2023.

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Authorizing Statute(s): EO: EO 14001 Name/Subject of EO: A Sustainable Public Health Supply Chain
   EO: EO 13987 Name/Subject of EO: Organizing and Mobilizing the United States Government To Provide a Unified and Effective Response
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU82	Final or interim final rulemaking	87 FR 71748	11/23/2022

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 44502	07/26/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 67920	11/10/2022
Did the Agency receive public comments on this ICR? No

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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
Supplemental to Form CMS-2552-10, Payment Adjustment for Domestic NIOSH-Approved Surgical N95 Respirators	CMS-10821	Supplement to Form CMS-2552-10

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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	4,662	0	0	4,662	0	0
Annual Time Burden (Hours)	2,331	0	0	2,331	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: This is a new information collection request.

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Annual Cost to Federal Government: $173,700

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: 12/02/2022

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