Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated With Section 1115 Demonstrations in the Medicaid Fraction (CMS-10839)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10839.Supporting Statement Part A (final rule).docx	Supporting Statement A	Uploaded 2023-08-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260509	Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated with Section 1115 Demonstrations in the Medicaid Fraction		Modified

ICR Details

OMB Control No: 0938-1447	ICR Reference No: 202308-0938-014
Status: Received in OIRA	Previous ICR Reference No: 202305-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated With Section 1115 Demonstrations in the Medicaid Fraction (CMS-10839)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/28/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,904,968	0
Time Burden (Hours)	494,536	0
Cost Burden (Dollars)	0	0

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Abstract: CMS issued a proposed rule (CMS-1788-P, RIN 0938-AV17) (88 FR 12623) with a proposal to refine our policy for counting inpatient days associated with patients who are regarded as eligible for medical assistance under a State Medicaid plan to include those who receive health insurance authorized by a section 1115 demonstration or patients who pay for all of the cost of such health insurance with premium assistance authorized by a section 1115 demonstration and such health insurance provides inpatient coverage.

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Authorizing Statute(s): US Code: 42 USC 1395ww Name of Law: The Social Security Act, Title XVIII
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV17	Final or interim final rulemaking	88 FR 58640	08/28/2023

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Federal Register Notices & Comments

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
Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated with Section 1115 Demonstrations in the Medicaid Fraction

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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	1,904,968	0	0	1,904,968	0	0
Annual Time Burden (Hours)	494,536	0	0	494,536	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. The burden has been adjusted in the final rule ICR because the number of respondents increased from 310 to 340. Similarly, the cost to the Federal government has been adjusted to account for the increased number of respondents and responses.

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Annual Cost to Federal Government: $1,098,064

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: 08/28/2023

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