CMS-855A - Supporting Statement

Supporting Statement for Paperwork Reduction Act Submissions Medicare Enrollment Application for Institutional Providers (CMS-855A, OMB 0938-0685)

BACKGROUND

The primary function of the CMS-855A Medicare enrollment application is to gather information from a certified provider or certified supplier (hereafter occasionally and collectively referenced as “provider(s)”) that tells us who it is, whether it meets certain qualifications to be a health care provider, where it practices or renders services, the identity of its owners, and other information necessary to establish correct claims payments.

This request for revision of a currently approved CMS-855A collection is associated with two final rules.

The first is the Calendar Year (CY) 2024 Home Health Prospective Payment System (HH PPS) final rule (CMS-1780-F), published in the Federal Register on November 13, 2023 (88 FR 77676).¹ We finalized in this rule a change to § 424.550(b) requiring hospices undergoing a change in majority ownership (CIMO) (as defined in 42 CFR § 424.502) within 36 months after their initial enrollment in Medicare or most recent CIMO to enroll in Medicare as a new hospice. This would require the hospice to submit an initial CMS-855A enrollment application instead of a CMS-855A change of information or change of ownership application. Due to the greater burden associated with completing an initial CMS-855A application versus a CMS-855A change of information, we projected in the final rule an increase in the currently approved CMS-855A information collection burden for initial applications. (See Section 12(d) for another requested change to the Form CMS-855A stemming from CMS-1780-F.)

The second is the final rule titled “Medicare and Medicaid Programs; Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities; Medicare Providers’ and Suppliers’ Disclosure of Private Equity Companies and Real Estate Investment Trusts” (CMS-6084-F), published in the Federal Register on November 17, 2023 (88 FR 80141). This rule implements section 1124(c) of the Social Security Act (the Act), which requires Medicare skilled nursing facilities (SNFs) to disclose certain information regarding their owners, operators, and related parties. (Section 1124(c)’s requirements for Medicare SNFs were codified in new 42 CFR § 424.516(g).) This data will be reported via the CMS-855A. We explained in the final rule that this will increase the currently approved CMS- 855A information collection burden for initial applications, revalidations, changes of ownership, and changes of information.

¹ Medicare Program; Calendar Year (CY) 2024 Home Health (HH) Prospective Payment System Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin Items and Services; Hospice Informal Dispute Resolution and Special Focus Program Requirements, Certain Requirements for Durable Medical Equipment Prosthetics and Orthotics Supplies; and Provider and Supplier Enrollment Requirements.

Sections 12 and 15 of this supporting statement will: (1) outline the CMS-855A information collection burden increases associated with these two rules; and (2) identify the changes to the CMS-855A that we are requesting pursuant to CMS-6084-F to collect the information described in section 1124(c).

1. JUSTIFICATION

1. Need and Legal Basis

Various sections of the Act, the United States Code (U.S.C.), Internal Revenue Service (IRS) Code and the CFR require providers and suppliers to furnish information concerning the amounts due and the identification of individuals or entities that furnish medical services to beneficiaries before payment can be made.

• Sections 1814(a), 1815(a), and 1833(e) of the Act require the submission of information necessary to determine the amounts due to a provider or other person.

• Section 1842(r) of the Act requires us to establish a system for furnishing a unique identifier for each physician who furnishes services for which payment may be made. To do so, we need to collect information unique to that provider or supplier.

• The Balanced Budget Act of 1997 (BBA) (Public Law 105-33), section 4313, amended sections 1124(a)(1) and 1124A of the Act to require disclosure of both the employer identification number (EIN) and social security number (SSN) of each provider or supplier, each person with ownership or control interest in the provider or supplier, and any managing employees.

• Section 31001(I) of the Debt Collection Improvement Act of 1996 (DCIA) (Public Law 104- 134) amended 31 U.S.C. 7701 by adding paragraph (c) to require that any person or entity doing business with the federal government provide their tax identification number (TIN).

• Sections 1866(b)(2)(D) and 1842(h)(8) of the Act require denial of enrollment (directly or indirectly) of persons convicted of a felony for a period not less than 10 years from the date of conviction.

• The IRS Code, section 3402(t), requires us to collect additional information about the proprietary/non-profit structure of a Medicare provider/supplier to allow exclusion of non- profit organizations from the mandatory 3% tax withholding.

• The IRS section 501(c) requires each Medicare provider/supplier to report information about its proprietary/non-profit structure to the IRS for tax withholding determination.

• Section 6401 of the Affordable Care Act (which amended section 1866(j) of the Social Security Act) outlines requirements for the enrollment of providers and suppliers into the Medicare program.

• Section 1124(c) of the Act requires Medicare SNFs to disclose the information described in that paragraph and which pertains to the SNF’s owners, operators, and related parties.

• We are authorized to collect information on the CMS-855 (Office of Management and Budget (OMB) approval number 0938-0685) to ensure that correct payments are made to providers and suppliers under the Medicare program as established by Title XVIII of the Act.

The CMS-855A application collects this information, including the data required to uniquely identify and enumerate the provider/supplier. Additional information needed to process claims accurately and timely is also collected on the application.

2. Purpose and Users of the Information

The CMS-855A application is submitted at the time the applicant first requests Medicare enrollment. The application is used by Medicare contractors to collect data to ensure that the applicant has the necessary credentials to provide the health care services for which they intend to bill Medicare. This includes data that allows the Medicare contractor to correctly price, process, and pay the applicant’s claims. It also gathers information that enables Medicare contractors to ensure that the provider is neither sanctioned from the Medicare program nor debarred, suspended, or excluded from any other federal agency or program. The application is also used by enrolled providers when they are reporting a change in their ownership, a change in their current Medicare enrollment information, or are revalidating or reactivating their Medicare enrollment.

3. Improved Information Techniques

This collection lends itself to electronic collection methods. The Provider Enrollment, Chain and Ownership System (PECOS) is a secure, intelligent, and interactive national data storage system maintained and housed within the CMS Data Center with limited user access through strict CMS systems access protocols. Access to the data maintained in PECOS is limited to CMS and Medicare contractor employees responsible for provider/supplier enrollment activities. The data stored in PECOS mirrors the data collected on the CMS-855 (Medicare Enrollment Applications) and is maintained indefinitely as both historical and current information. CMS also supports an internet-based provider/supplier CMS-855 enrollment platform, which allows the provider/supplier to complete an online CMS-855 enrollment application and transmit it to the Medicare contractor database for processing; the data is then transferred from the Medicare contractor processing database into PECOS by the Medicare

contractor. Periodically, CMS will require adjustment to the format of the CMS-855 form (either paper, electronic or both) for clarity or to improve form design. These adjustments do not alter the current OMB data collection approval.

4. Duplication and Similar Information

There is no duplicative information collection instrument or process.

5. Small Business

The data collections associated with the CMS-855 application process impacts small businesses. However, because of the relative infrequency with which the information needs to be submitted, we believe the overall impact on small businesses is negligible. In addition, these businesses have been required to provide CMS with much of the same information to enroll in the Medicare program and for CMS to successfully process their claims.

6. Less Frequent Collections

This information is collected on an as needed basis. The information provided on the CMS-855 is required for enrollment in the Medicare program. It is essential to collect this data the first time a provider/supplier enrolls with a Medicare contractor so that CMS’ contractors can ensure that the provider/supplier meets all statutory and regulatory requirements necessary for enrollment and that claims are paid correctly.

In addition, to ensure uniform data submissions, CMS requires that all changes to previously submitted enrollment data be reported via the appropriate provider enrollment application.

7. Special Circumstances

There are no special circumstances that will require an information collection to be conducted in a manner that requires respondents to:

• Submit more than an original and two copies of any document.

• Retain records -- other than health, medical, government contract, grant-in-aid, or tax records -- for more than three years.

• Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study.

• Use a statistical data classification that has not been reviewed and approved by OMB.

• Include a pledge of confidentiality: (1) that is not supported by authority established in statute or regulation; (2) that is not supported by disclosure and data security policies consistent with that pledge; and/or (3) which unnecessarily impedes the sharing of data with other agencies for compatible confidential use.

• Submit proprietary trade secret or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. Federal Register Notice/Outside Consultation

1. November 13, 2023, Final Rule (CMS-1780-F)

Serving as the 60-day notice, CMS-1780-P (RIN 0938-AV03) was filed for public inspection on June 30, 2023. It was published in the Federal Register on July 10, 2023 (88 FR 43654). We did not receive any PRA-related comments on our provider enrollment provisions.

The final rule (CMS-1780-F, RIN 0938-AV03) was published in the Federal Register on November 16, 2023 (88 FR 77676).

2. November 17, 2023, Final Rule (CMS-6084-F)

Serving as the 60-day notice, CMS-6084-P (RIN 0938-AU90) was filed for public inspection on February 13, 2023. It was published in the Federal Register on February 15, 2023 (88 FR 9820). We did not receive any PRA-related comments.

The final rule, as previously noted, was published in the Federal Register on November 17, 2023.

9. Payment/Gift to Respondents

N/A.

10. Confidentiality

Except as explained in Section 16 of this Supporting Statement: (1) all information collected will be kept private in accordance with 5 U.S.C. 552(b)(4), Executive Order 12600, and 45 CFR

155.260 (Privacy and Security of Personally Identifiable Information); and (2) privileged or confidential commercial or financial information is protected from public disclosure by federal law.

11. Sensitive Questions

There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. CMS-855A Request for Revision of Currently Approved Collection (RRCAC)

As discussed in the Background section of this supporting statement, there are several components of this RRCAC. The first involves the information collection burden estimates associated with our hospice CIMO provision in CMS-1780-F. The second involves the information collection burden estimates associated with our SNF information disclosure provisions in CMS-6084-F. The third pertains to changes we request to make to the CMS-855A to collect the SNF data referenced in section 1124(c) of the Act (hereafter occasionally referenced as simply “section 1124(c)”). The fourth involves two minor data elements we are adding to Sections 4 and 6 of the existing Form CMS-855A; these elements pertain exclusively to hospices.

1. CMS-1780-F Burden Estimates

The principal information collection burden of the hospice CIMO requirement, as previously noted, will involve the completion of an initial CMS-855A application rather than a CMS-855A change of ownership (CHOW) application or a CMS-855A change of information application. Consistent with the general time estimates we have typically used for these three categories of applications, it takes a provider approximately 4 hours to complete an initial CMS-855A application, 4 hours for a CMS-855A CHOW application, and 1 hour for a CMS-855A change of information application. The primary burden difference, therefore, will be between submitting an initial application and submitting a change of information (since there is no burden difference between an initial application and a CHOW application).

Based on internal CMS data, we estimated in CMS-1780-F that each year approximately 50

hospices will be required to initially enroll in Medicare due to a CIMO versus reporting the sale via a change of information. This results in an additional annual CMS-855A hour burden of 150 hours (50 x 3 hours), with the 3-hour figure reflecting the difference between initial applications and changes of information. Regarding cost, it has been our experience that CMS-855A applications are completed by the provider’s office staff. We will use the following median wage category and hourly rate from the U.S. Bureau of Labor Statistics’ (BLS) May 2023 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm):

TABLE 1: NATIONAL OCCUPATIONAL EMPLOYMENT AND WAGE ESTIMATES – OFFICE AND ADMINISTRATIVE SUPPORT WORKERS, ALL OTHERS

Occupation Title	Occupation Code	Median Hourly Wage ($/hr)	Fringe Benefits and Overhead ($/hr)	Adjusted Hourly Wage ($/hr)
Office and Administrative Support Workers, All Other	43-9199	20.78	20.78	41.56

This results in an additional annual cost burden for CMS-855A applications of $6,234 (150 hours x $41.56).

2. SNF Data Burden Estimates as Calculated in CMS-6084-F

We noted in CMS-6084-F that the current CMS-855A already collects much of the information that SNFs will have to disclose under section 1124(c). Examples of this data include the SNF’s owners, managing employees and organizations, corporate officers, corporate directors, and other parties. However, certain information is not collected via the existing CMS-855A process. This includes (but is not limited to) parties that perform administrative, financial, or clinical consulting services but do not otherwise qualify a person or entity that must otherwise be reported on the application. For instance, suppose a particular SNF hires Company X to furnish certain financial services for the SNF. If X does not qualify as an owning or managing organization of the SNF, reporting X would constitute new information collection burden on the SNF. (See discussion in Section 12(c)(ii) below for more information on this topic.) Accordingly, disclosure of these new data elements (hereafter occasionally referenced as “supplemental data”) will constitute additional burden on the SNF community.

Among the data required per section 1124(c) is that pertaining to the SNF’s “additional disclosable parties” (ADPs). Under section 1124(c)(2)(A)(ii)(III), the SNF must disclose its ADPs. Section 1124(c)(5)(A) defines an ADP as a party that:

• Exercises operational, financial, or managerial control over the facility or a part thereof, or provides policies or procedures for any of the operations of the facility, or provides financial or cash management services to the facility;

• Leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property; or

• Provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility.

As previously indicated, there will be four principal types of CMS-855A transactions via which SNFs will report supplemental data per new § 424.516(g): (1) applications to initially enroll in Medicare; (2) CHOW applications; (3) applications to revalidate the SNF’s current enrollment information per § 424.515; and (4) reporting changes to any of the SNF’s previously disclosed supplemental data per § 424.516.

We stated above that CMS-855A applications are typically completed by the provider’s office staff. However, given the potential complexity of the supplemental data to be reported (and as noted in CMS-6084-F), the SNF’s legal counsel may be involved in reviewing this information. Hence, along with the above-mentioned wage category for “Office and Administrative Support Workers, All Other”, we used in CMS-6084-F the following wage category and rates (updated to May 2023, the most recent available figures) from the BLS National Occupational Employment and Wage Estimates for all salary estimates (https://www.bls.gov/oes/current/oes_nat.htm):

TABLE 2: NATIONAL OCCUPATIONAL EMPLOYMENT AND WAGE ESTIMATES - LAWYERS

Occupation Title	Occupation Code	Median Hourly Wage ($/hr)	Fringe Benefits and Overhead ($/hr)	Adjusted Hourly Wage ($/hr)
Lawyers	23-1011	70.08	70.78	141.56

Based on our internal data, and as stated in the final rule, we estimated that each year approximately: (1) 1,055 SNFs will submit an initial CMS-855A enrollment application; (2) 1,672 will submit a CMS-855A revalidation application; (3) 951 will submit a CMS-855A CHOW application; and (4) 4,500 will report new or changed supplemental data via a CMS- 855A change of information application. Furthermore, we projected that it would take the SNF an average of 2.25 hours to furnish the supplemental data for initial, revalidation, and CHOW applications and 1 hour for changes of information. (We recognized that the actual time for a particular SNF could be more or less than these figures.) Of these hour estimates, we projected that the burden will be split evenly between the SNF’s administrative staff and legal counsel (for example, 1.125 hours each for initial and revalidation applications). With this equal division, the per hour wage will be $91.56 (($41.56 + $141.56)/2). As outlined in the final rule and in Table 3 below, this resulted in an estimated annual ICR burden of our Medicare SNF disclosure provisions of 12,776 hours at a cost of $1,169,770.

TABLE 3: HOUR AND BURDEN ESTIMATES FOR NURSING HOME DISCLOSURE

PROVISIONS AS STATED IN CMS-6084-F

	OMB Control No.	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Medicare
Initial Form CMS-855A Applications	0938-0685	1,055	1,055	2.25	2,374	91.56	217,363
Form CMS-855A Revalidation Applications	0938-0685	1,672	1,672	2.25	3,762	91.56	344,449
Form CMS-855A Change of Ownership Applications	0938-0685	951	951	2.25	2,140	91.56	195,938
Form CMS-855A Change of Information Applications	0938-0685	4,500	4,500	1	4,500	91.56	412,020
Totals	N/A	8,178	8,178	N/A	12,776	N/A	1,169,770

Upon further reflection, however, and after analyzing the individual burden of each of our requested new data elements on the CMS-855A, we believe the total hour and cost burdens cited in CMS-6084-F are too low. That is, while we estimated in CMS-6084-F that furnishing the supplemental data will take 2.25 hours, we believe that combining the burden of each data element discussed in Section 12(d) below results in a total greater than 2.25 hours. We will therefore use the burden estimates in Section 12(d) (rather than those in CMS-6084-F) as part of this requested collection revision.

We will also use in Section 12(d) the BLS May 2023 median (rather than mean) wage estimates for the categories of Office and Administrative Support Workers, All Other (shown above) and Lawyers, the latter being $70.78 – or $141.56 with 100% fringe benefits. Using the combined hourly wage of these two categories results in a uniform rate of $91.56 (or ($141.56 +

$41.56)/2))

3. Revised/Increased SNF Data Burden Estimates Per This PRA Package

1. Background and Organizational Change

This Section 12(c) outlines the changes to the CMS-855A for which we are requesting approval and the anticipated information collection burden associated with each data element.

Consistent with section 1124(a) of the Act, Sections 5 and 6 of the current CMS-855A require the provider (including SNFs) to report the following:

• Individuals and entities with a 5 percent or greater direct or indirect ownership interest in the provider.

• Individuals and entities with any general or limited partnership interest in the provider, regardless of the percentage.

• All entities with a 5 percent or greater mortgage, deed of trust, or other security interest in the provider.

• If the provider is a corporation, all the provider’s officers and directors.

• All managing employees and managing organizations of the provider.

For each reported individual and entity (hereafter occasionally and collectively referenced as

“party”), the provider must furnish: (1) basic identifying information (e.g., name, tax identification number, entity address); (2) data regarding the type of party (e.g., corporation, private equity company) and the party’s relationship to the provider (e.g., 5% or greater owner, managing employee), and (3) whether the party has any adverse legal history.

We considered revising Sections 5 and 6 of the CMS-855A to capture the supplemental data required under section 1124(c). Yet we believe this could prove confusing to stakeholders to have certain data elements in these sections apply to all providers while others only pertain to SNFs. In other words, there would be one set of reporting requirements for hospices (specifically, the data required under section 1124(a)) and another for SNFs (the section 1124(a) and section 1124(c) data). To avoid this confusion, we request to revise the CMS-855A such that:

• Providers other than SNFs will continue to complete Sections 5 and 6.

• SNFs will no longer complete Sections 5 and 6 but will instead complete a new, separate attachment at the end of the CMS-855A that collects: (i) the data currently required in Sections 5 and 6 per section 1124(a); and (ii) additional data per section 1124(c).

Except for (1) revising the instructions to Sections 5 and 6 to exclude SNFs from their purview and (2) adding the SNF attachment, we are not making any changes to the CMS-855A.

2. SNF Attachment Data Elements

The SNF attachment data elements discussed in Section 12(d) below only involve the section 1124(c) supplemental data. Non-supplemental data on the attachment, such as 5 percent or greater owners, would not constitute new burden for SNFs since they already must report this information per section 1124(a). Section 12(d) therefore does not discuss this data. However, we stress to non-SNFs that some of the parties identified in section 1124(c) may need to be reported in Section 5 or 6 because they fall within one of the categories of parties currently captured in Section 5 or 6 and in section 1124(a). For example:

• Section 1124(c) requires the disclosure of parties that furnish cash management services to the provider. Although cash management service companies are not specifically mentioned in Section 5 or 6 or in section 1124(a), it is possible that a cash management services entity could qualify as a “managing organization” (as defined in § 424.502) under section 1124(a) and hence need to be reported in Section 5 by a provider other than a SNF.

• An officer of a corporation that is an ADP of the SNF must be reported per section 1124(c). Officers of ADP corporations are not explicitly mentioned in Section 5 or 6 or in section 1124(a), but such persons could qualify as a managing employee of the non- SNF provider (and thus need to be disclosed) if the individual meets the managing employee definition in § 424.502.

In this same vein, SNFs currently report some supplemental data in Sections 5 and 6 if the entity or individual in question falls within the categories of parties identified in those two sections. As

another example, an entity providing clinical consulting services (referenced in section 1124(c)) to the SNF may qualify as a managing organization of the SNF in certain circumstances. Given this, our burden estimates in Section 12(d) below contain the caveat that some of this information may already be reported in certain cases per section 1124(a).

The following assumptions and explanations apply to our Section 12(c)(2) estimates:

• Initial Applications and CHOW Applications - We will use the same annual number of initial and CHOW respondents and responses used in CMS-6084-F and shown in Table 3 above (that is, 1,055 and 951, respectively).

• Revalidation Applications - We will use an annual figure of 5,167 respondents and responses. We recognize that this is substantially higher than the 1,672 total utilized in CMS-6084-F. This is because we plan to conduct off-cycle revalidations under § 424.515(d) of each Medicare-enrolled SNF once the CMS-855A is revised to collect the section 1124(c) data. We expect to complete these revalidations within the first 3 years following CMS-

6084-F’s publication, most likely all in the first year. Since there are roughly 15,500 enrolled SNFs, this results in 5,167 annual revalidations over the 3-year OMB approval period (or 15,500/3).

• Changes of Information - The 4,500-figure cited in Table 3 (and which we utilized in CMS- 6084-F) was based on our estimate of the total annual number of SNFs that would report a change to any of their section 1124(c) supplemental data. Since this Section 12(d) breaks down each supplemental data element individually (which we did not do in CMS-6084-F), we believe it would be inaccurate to use the 4,500-figure in our burden projection for every element. We cannot assume that 4,500 SNFs will, for example, report changes in financial control, 4,500 will report changes in trustees, etc. The number of changes for a particular data element could be greater or fewer than 4,500. Moreover, because much of this data is new, we do not have existing information in PECOS upon which we can establish estimates of the frequency with which certain data will change. Our change of information projections below, therefore, are very general, and we request stakeholder feedback on their accuracy.

• Wage Estimates - We will use the above-referenced $91.56 hourly wage.

• Timeframe of Estimates – Except as otherwise noted, all estimates are annual.

• Application of Estimates – Except as otherwise noted, all estimates are for supplemental/section 1124(c) data rather than data currently required under section 1124(a).

ORGANIZATIONS

1. Sections A through C Excluding Parent Company Data Question

(The parent company data question is addressed in (II) below.)

Sections A through C of the SNF attachment contain the same data elements currently in Sections 5 and 7 (the latter collecting chain home office information) of the CMS-855A. This includes, for example, basic identifying information about the listed organization, the organization’s business type (corporation, private equity company, real estate investment trust, bank, etc.). Most organizations identified in Sections A through C must already be reported per section 1124(a), so this will not constitute new burden. For entities that must now be reported per section 1124(c) (e.g., ADPs), we estimate that it will take the SNF 1.75 hours to complete Sections A through C for all of them.

We also project that approximately 3,000 SNFs each year will report a change of information concerning the data in Sections A through C with an average burden of 15 minutes (.25 hours). This results in the following burden projections:

TABLE 4: HOUR AND BURDEN ESTIMATES FOR SECTION A THROUGH C DATA (EXCLUDING PARENT COMPANY DATA QUESTION)

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	1.75	1,846	91.56	169,020
Form CMS-855A Revalidation Applications	5,167	5,167	1.75	9,042	91.56	827,886
Form CMS-855A Change of Ownership Applications	951	951	1.75	1,664	91.56	152,356
Form CMS-855A Change of Information Applications	3,000	3,000	.25	750	91.56	68,670
Totals	10,173	10,173	N/A	13,302	N/A	1,217,932

2. Section B – Type of Organization – Parent Company Data

Each listed organization (including those that must be disclosed per section 1124(a)) must answer “Yes/No” to the following new question: “Is this organization the ultimate parent company in a multi-organizational group of entities?” Although this information is not specifically mentioned in either section 1124(c) or 1124(a), we believe it will help CMS identify the highest-level entity in the SNF’s ownership structure. We estimate that it will take the SNF 5 minutes (or .083 hours) to answer this question for their reported entities. Insofar as changes of information, this question would only need to be completed if (1) the SNF is reporting a new or changed organization in Section A or (2) the parent/non-status parent of an existing organization is changing. We believe the latter will be extremely infrequent but that the former will occur approximately 3,000 times per year with a burden of 1 minute (or .0167 hours) for completing this question.

This results in the following burden estimates for this data element:

TABLE 5: HOUR AND BURDEN ESTIMATES FOR SECTION B PARENT COMPANY

QUESTION

	Number of Respondents	Number of Responses *	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	.083	88	91.56	8,057
Form CMS-855A Revalidation Applications	5,167	5,167	.083	429	91.56	39,279
Form CMS-855A Change of Ownership Applications	951	951	.083	79	91.56	7,233
Form CMS-855A Change of Information Applications	3,000	3,000	.0167	50	91.56	4,578
Totals	10,173	10,173	N/A	647	N/A	59,147

3. Section D - Relationship to SNF

1. Questions 1 – 7

Questions 1 through 7 of Section D ask the SNF to identify whether the entity listed in Section A has any direct or indirect ownership interest in the SNF. The questions are delineated by organization type and whether the interest is direct or indirect; for example, Question 7 asks whether the limited liability company (LLC), general partnership, or limited partnership has any indirect ownership interest in the SNF. The SNF need only complete those questions in 1 through 7 applicable to the Section A organization’s business type (e.g., if the listed organization is an LLC, only Questions 2 and 7 must be completed). While much of this information is currently collected on the CMS-855A per section 1124(a) and therefore is not considered new burden, LLCs with a direct or indirect ownership interest in the SNF of less than 5 percent will now have to be reported consistent with section 1124(c).

We project the following:

• 10 percent of SNFs will report an entity an LLC described above via an initial, CHOW, or revalidation application.

• It will take the SNF 10 minutes (or .167 hours) to report the entity as well as the effective date and percentage of ownership.

• Approximately 50 SNFs each year will report---via a change of information---an LLC that is described above.

TABLE 6: HOUR AND BURDEN ESTIMATES FOR QUESTIONS 1 – 7 OF SECTION D

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	106	.167	18	91.56	1,648
Form CMS-855A Revalidation Applications	5,167	517	.167	86	91.56	7,847
Form CMS-855A Change of Ownership Applications	951	95	.167	16	91.56	1,465
Form CMS-855A Change of Information Applications	50	50	.167	8	91.56	732
Totals	7,223	768	N/A	128	N/A	11,692

2. Question 8 – Mortgage/Security Interest

Question 8 asks whether the organization listed in Section A has a 5% or greater mortgage or security interest in the SNF and, if so, to identify the interest. Section 1124(a) already requires such interests to be disclosed, so this will not constitute new burden.

3. Question 9 - Trustee

Question 9 asks whether the organization listed in Section A is a trustee of the SNF. We estimate that approximately one percent of SNFs (initials, revalidations, CHOWs) will report a trust in Section A, requiring them to also cite the effective date. We project that roughly 5 SNFs per year will report a new or changed trustee via a change of information and thus complete Question 9. We believe the Question 9 data will take the SNF approximately 5 minutes to furnish (or .083 hours). Our estimates are as follows:

TABLE 7: HOUR AND BURDEN ESTIMATES FOR QUESTION 9 OF SECTION D - TRUSTEES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	11	.083	1	91.56	92
Form CMS-855A Revalidation Applications	5,167	52	.083	4	91.56	366
Form CMS-855A Change of	951	10	.083	1	91.56	92

Ownership Applications
Form CMS-855A Change of Information Applications	5	5	.083	0	91.56	0
Totals	7,178	78	N/A	6	N/A	550

4. Question 10 – Control

Question 10 asks whether the organization listed in Section A exercises direct or indirect operational, managerial, or financial control over the SNF or any part of the SNF. The CMS- 855A already collects data regarding operational and managerial control, including (1) the type and effective date of control and (2) whether the control is furnished under contract. Although “financial control” is not explicitly mentioned on the current CMS-855A, some forms of financial control may already be reported as a sub-category of operational/managerial control (e.g., the financial entity exercises operational control). We have no means of estimating the frequency with which this occurs because, again, financial control is not listed on the existing form. For purposes of this information collection request, financial control will be considered supplemental (and thus new) data for which a burden must be estimated.

The other new data element is that the SNF must identify the part(s) of the SNF over which the entity has operational, managerial, or financial control.

We project the following:

• Financial control

• Initials/Revalidations/CHOWs – 80 percent of SNFs will report in Section A (per section 1124(c)) an entity that exercises financial control over the SNF, hence requiring completion of the Question 10 data.

• Changes of Information – 400 SNFs will report a new or changed financially controlling entity in Section A and accordingly complete Question 10.

• The Question 10 data (excluding the data element concerning parts of the SNF, which is addressed below) will take 12 minutes (0.2 hours) to complete.

• Parts of the SNF

• Initials/Revalidations/CHOWs – It will take the SNF 30 minutes (0.5 hours) to disclose the parts of the SNF that the reported entities control.

• Changes of Information – 1,000 SNFs will report a new or changed entity in Section A and consequently disclose the parts of the SNF that the entity controls with a burden of 3 minutes (0.05 hours).

TABLE 8: HOUR AND BURDEN ESTIMATES FOR QUESTION 10 OF SECTION D -

CONTROL AND PARTS OF SNFs

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Financial Control
Initial Form CMS-855A Applications	1,055	844 *	0.2	169	91.56	15,474
Form CMS-855A Revalidation Applications	5,167	4,134 *	0.2	827	91.56	75,720
Form CMS-855A Change of Ownership Applications	951	761 *	0.2	152	91.56	13,917
Form CMS-855A Change of Information Applications	400	400	0.2	80	91.56	7,325
Totals	7,573	6,139	N/A	1,228	N/A	112,436
Parts of SNF
Initial Form CMS-855A Applications	1,055	1,055	0.5	528	91.56	48,344
Form CMS-855A Revalidation Applications	5,167	5,167	0.5	2,584	91.56	236,591
Form CMS-855A Change of Ownership Applications	951	951	0.5	476	91.56	43,583
Form CMS-855A Change of Information Applications	1,000	1,000	0.05	50	91.56	4,578
Totals	8,173	8,173	N/A	3,638	N/A	333,096
Question 10 Total Burden	15,746	14,312	N/A	4,866	N/A	445,532

(* 80 percent of 1,055; 5,167; and 951, respectively.)

5. Question 11 - Services Provided

Question 11 asks whether the organization listed in Section A furnishes any of the following (directly or indirectly) to the SNF:

• Policies and procedures for any of the SNF’s operations

• Financial services

• Cash management services

• Management services

• Administrative services

• Clinical consulting services

• Accounting services

The SNF must respond “Yes/No” to each of these bulleted services. If the SNF answers “Yes” to any of them, it must disclose the effective date, the type of services, and whether the services are furnished under contract. This represents supplemental data, for all these services are

referenced in section 1124(c) but are not specifically listed in section 1124(a). Though some services, such as management and administrative services, may fall within types of managing organizations that must currently be reported on the CMS-855A, we will consider these new data elements strictly for purposes of this information collection request.

We estimate the following:

• Initials/Revalidations/CHOWs: It will take the SNF 40 minutes (0.67 hours) to complete this section for its reported entities.

• Changes of Information

• 1,000 SNFs per year will report a new or changed entity in Section A, thus requiring the completion of Question 11 and, if applicable, the furnishing of data regarding the services. The burden of the latter will be 5 minutes (0.083 hours).

TABLE 9: HOUR AND BURDEN ESTIMATES FOR QUESTION 11 OF SECTION D – SERVICES FURNISHED

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS-855A Applications	1,055	1,055	0.67	707	91.56	64,733
Form CMS-855A Revalidation Applications	5,167	5,167	0.67	3,462	91.56	316,981
Form CMS-855A Change of Ownership Applications	951	951	0.67	637	91.56	58,324
Form CMS-855A Change of Information Applications	1,000	1,000	.083	83	91.56	7,599
Totals	8,173	8,173	N/A	4,889	N/A	447,637

6. Question 12 – Leases

Question 12 asks whether the organization listed in Section A leases or subleases real property to the SNF. As CMS does not presently collect this information and it must be disclosed per section 1124(c), this constitutes new burden. If the SNF responds “Yes,” it must describe the lease arrangement and its type and length, a burden we estimate to be 20 minutes (or 0.33 hours). We estimate that 20 percent of SNFs (initials, revalidations, CHOWs) will list an entity in Section A that falls within this category. We also project that 50 SNFs per year will report a new or changed lessor as part of a change of information and will provide the Question 12 data. This results in the following burden estimates.

TABLE 10: HOUR AND BURDEN ESTIMATES FOR QUESTION 12 OF SECTION D -

LEASES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	211 *	0.33	70	91.56	6,409
Form CMS-855A Revalidation Applications	5,167	1,033 *	0.33	341	91.56	31,222
Form CMS-855A Change of Ownership Applications	951	190 *	0.33	63	91.56	5,768
Form CMS-855A Change of Information Applications	50	50	0.33	17	91.56	1,557
Totals	7,223	1,484	N/A	491	N/A	44,956

(* 20 percent of 1,055; 5,167; and 951, respectively.)

7. Question 13 – Ownership of SNF Real Property

Question 13 asks whether the organization listed in Section A directly or indirectly owns at least 5 percent of the SNF’s real property or the real property on/in which the SNF operates. Since CMS does not currently collect this information and it must be disclosed per section 1124(c), this constitutes new burden. If the SNF responds “Yes,” it must: (i) list the effective date; and (ii) identify whether the ownership is of the SNF’s real property or of real property the SNF leases or subleases. We estimate that all SNFs will report at least one such entity in Section A and furnish the requested Question 13 information, a burden we project will take 20 minutes (or 0.33 hours). We also estimate that 300 SNFs per year will report a new or changed real estate owner as part of a change of information and will provide the Question 13 data. Our burden estimates are as follows:

TABLE 11: HOUR AND BURDEN ESTIMATES FOR QUESTION 13 OF SECTION D – REAL PROPERTY

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	0.33	352	91.56	32,229
Form CMS-855A Revalidation Applications	5,167	5,167	0.33	1,722	91.56	157,666
Form CMS-855A Change of	951	951	0.33	317	91.56	29,025

Ownership Applications
Form CMS-855A Change of Information Applications	300	300	0.33	100	91.56	9,156
Totals	7,473	7,473	N/A	2,491	N/A	228,076

8. Questions 14 through 18 - Ownership Structures of ADPs

Section 1124(c)(2)(A)(iii) requires the SNF to disclose the organizational structure of each ADP. Section 1124(c)(5)(D) defines “organization structure,” in part, as any of the following:

• If the ADP is a corporation - The officers, directors, and 5 percent or greater direct or indirect owners of the corporation.

• If the ADP is an LLC - The members and managers of the LLC.

• If the ADP is a general partnership – All general partners.

• If the ADP is limited partnership – All general partners as well as limited partners with at least a 10 percent ownership interest in the limited partnership.

• If the ADP is a trust, all trustees.

CMS has long collected information about the owners of SNFs. However, data regarding the owners of the SNF’s lessors, managing companies, consultants, and other organizations listed in section 1124(c)(5)(A) typically has not been reported unless those parties have an otherwise reportable ownership or managerial interest in the SNF. (To illustrate, if an ADP’s corporate officer exercises managerial control over the SNF, he/she must be reported per section 1124(a).) We believe this latter situation is infrequent because ADP owners and corporate officers/directors may be too organizationally distant from the SNF to fall within the scope of parties listed in section 1124(a). We will therefore assume for purposes of this information collection request that the information in sections 1124(c)(2)(A)(iii) and (c)(5)(D) constitutes new burden.

Questions 14 through 18 collect data on the ADP’s organizational owners, partners, and trustees. (Individuals such as directors are addressed later in the SNF attachment and this supporting statement.) Prior to this set of questions, the SNF must provide identifying data on each such owner/partner/trustee similar to that contained in Section A (e.g., legal business name, address). Questions 14 through 18 are specific to the ADP’s organization type (e.g., Question 14 pertains to ADPs that are corporations; Question 17 pertains to limited partnerships; etc.) Within each question are data elements such as: (i) a description of the interest; and (ii) the effective date and percentage of ownership.

We estimate the following:

• Initials/Revalidations/CHOWs: It will take the SNF 45 minutes (or 0.75 hours) to complete Questions 14 through 18 for its ADPs. All SNFs will report at least one ADP.

• Changes of Information – 500 SNFs per year will report a new or changed ADP organizational owner/partner/trustee (and/or new/changed data thereon) in Questions 14 – 18. This will be pursuant to: (1) a newly reported ADP; (2) a new or changed owner of an existing ADP; and/or (3) new changed data regarding a current ADP. The burden will be 10 minutes (or .167 hours).

TABLE 12: HOUR AND BURDEN ESTIMATES FOR QUESTIONS 14 – 18 OF SECTION D – ADP OWNERSHIP STRUCTURES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS-855A Applications	1,055	1,055	0.75	791	91.56	72,424
Form CMS- 855A Revalidation Applications	5,167	5,167	0.75	3,875	91.56	354,795
Form CMS- 855A Change of Ownership Applications	951	951	0.75	713	91.56	65,282
Form CMS- 855A Change of Information Applications	500	500	.167	84	91.56	7,691
Totals	7,673	7,673	N/A	5,463	N/A	500,192

9. Interests in ADP(s)

Question 19 asks whether the ADP owner/trustee/LLC manager (as indicated in Question 14, 15, 16, 17, or 18) has an ownership/trustee/LLC managerial interest in the SNF itself or in another ADP of the SNF. If the SNF answers “Yes,” the SNF must list the legal business name of that entity, a burden we estimate to be 20 minutes (or 0.33 hours). We estimate that 20 percent of SNFs (initials, revalidations, CHOWs) will answer “Yes” and list an entity in Question 19. We also project that 100 SNFs per year will report a new or changed entity in Question 19. This results in the following burden estimates.

TABLE 13: HOUR AND BURDEN ESTIMATES FOR QUESTION 19 OF SECTION D -

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	211 *	0.33	70	91.56	6,409
Form CMS-855A Revalidation	5,167	1,033 *	0.33	341	91.56	31,222

Applications
Form CMS-855A Change of Ownership Applications	951	190 *	0.33	63	91.56	5,768
Form CMS-855A Change of Information Applications	100	100	0.33	33	91.56	3,021
Totals	7,273	1,534	N/A	507	N/A	46,420

(* 20 percent of 1,055; 5,167; and 951, respectively.)

4. Section E - Final Adverse Actions

The SNF must disclose whether the organization listed in Section A has had one or more of the adverse actions listed in Section 3 of the CMS-855A imposed against them. SNFs are currently required to submit this data regarding entities listed in Section 5 of the CMS-855A. Furnishing this information on the SNF attachment thus will not constitute new burden. We estimate, however, that two percent of SNFs (initials, revalidations, CHOWs) will report at least one entity per section 1124(c) (e.g., an ADP) with an adverse action. We also project that 10 SNFs per year will report a new or changed entity in Section A that has an adverse action. We further estimate that providing this adverse legal action data will take 30 minutes (or 0.5 hours). This results in the following new burden:

TABLE 14: HOUR AND BURDEN ESTIMATES FOR ADVERSE ACTION DATA IN SECTION E – FINAL ADVERSE ACTIONS

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	21	0.5	11	91.56	1,007
Form CMS-855A Revalidation Applications	5,167	103	0.5	52	91.56	4,761
Form CMS-855A Change of Ownership Applications	951	19	0.5	10	91.56	916
Form CMS-855A Change of Information Applications	10	10	0.5	5	91.56	458
Totals	7,183	153	N/A	78	N/A	7,142

INDIVIDUALS

(This subsection pertains to individuals.)

1. Section A – Identifying Data of Listed Individual

Section A of the SNF attachment contains the same basic identifying data elements currently in Section 6 of the CMS-855A. For initial, revalidation, and CHOW applications, we believe it will take 2 hours for the SNF to complete Section A for all reported individuals who must be disclosed per section 1124(c). We project that 3,000 SNFs annually will report a new or changed individual (or a change in data pertaining to an existing individual) in Section A per a change of information application, a burden we estimate to be 15 minutes (or .25 hours).

TABLE 15: HOUR AND BURDEN ESTIMATES FOR SECTION A – IDENTIFYING

DATA

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	2	2,110	91.56	193,192
Form CMS-855A Revalidation Applications	5,167	5,167	2	10,334	91.56	946,181
Form CMS-855A Change of Ownership Applications	951	951	2	1,902	91.56	174,147
Form CMS-855A Change of Information Applications	3,000	3,000	.25	750	91.56	68,670
Totals	10,173	10,173	N/A	15,096	N/A	1,382,190

2. Section B - Relationship to SNF

1. Questions 1 – 7

Questions 1 through 7 of Section B ask the SNF to identify whether the person listed in Section A has a direct or indirect ownership interest in the SNF. The questions are delineated by organization type and whether the interest is direct or indirect. The SNF need only complete those queries in 1 through 7 applicable to the SNF’s business type.

Much of this data is currently disclosed consistent with section 1124(a). As with Questions 1 through 7 in the Organizations section of the SNF attachment, however, there is a new category of supplemental data pursuant to section 1124(c) – if the SNF is an LLC, persons with a direct or indirect ownership interest in the SNF of less than 5 percent.

We project the following:

• 10 percent of SNFs will report a person described above via an initial, CHOW, or revalidation application.

• It will take the SNF 10 minutes (or .167 hours) to report the individual as well as the effective date and percentage of ownership.

• Approximately 50 SNFs each year will report---via a change of information---an individual described above.

TABLE 16: HOUR AND BURDEN ESTIMATES FOR QUESTIONS 1 – 7– DESCRIPTION OF OWNERSHIP INTEREST

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	106	.167	18	91.56	1,648
Form CMS-855A Revalidation Applications	5,167	517	.167	86	91.56	7,874
Form CMS-855A Change of Ownership Applications	951	95	.167	16	91.56	1,465
Form CMS-855A Change of Information Applications	50	50	.167	8	91.56	732
Totals	10,173	10,173	N/A	128	N/A	11,719

2. Question 8 – Corporate Officer or Director

Question 8 asks whether, if the SNF is a corporation, the individual is an officer or director of the SNF. Furnishing this data will not constitute new burden because corporate officers and directors must already be disclosed per section 1124(a).

3. Question 9 – Other Governing Body Members

Question 9 asks whether, if the SNF has a business structure other than that of a corporation, whether the person is a member of the SNF’s governing body. We believe that many of these individuals are already reported per section 1124(a) as managing employees and/or partners. In this context, Question 9 would not constitute new burden. With respect to governing body members, however, only if the SNF is a corporation must the SNF list them as such under section 1124(a). Disclosing all governing body members of other business types, such as LLCs, is not required. This would constitute new burden.

We cannot ascertain how many non-corporation SNFs have reported their governing body members as managing employees. We can, however, state that roughly 30 percent of enrolled SNFs are corporations. For purposes of this information collection request, therefore, we will project that 70 percent of the SNF universe (e.g., non-corporations, such as LLCs) will disclose information (title and effective date) about their governing body members in Question 9, a task we estimate will take 30 minutes (or 0.5 hours). We further estimate that 500 SNFs per year will

report a new or changed governing body member and accordingly provide the Question 9 data with a burden of 10 minutes (or .167 hours). Table 17 outlines the burden associated with Question 9.

TABLE 17: HOUR AND BURDEN ESTIMATES FOR QUESTION 9 – GOVERNING BODY MEMBERS

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	739 *	0.5	370	91.56	33,877
Form CMS-855A Revalidation Applications	5,167	3,623 *	0.5	1,812	91.56	165,907
Form CMS-855A Change of Ownership Applications	951	666 *	0.5	333	91.56	30,489
Form CMS-855A Change of Information Applications	500	500	.167	84	91.56	7,691
Totals	7,673	5,528	N/A	2,599	N/A	237,964

(* 70 percent of 1,055; 5,176; and 951, respectively.)

4. Question 10 – Mortgage/Security Interest

Question 10 asks whether the individual has a 5 percent or greater mortgage or security interest in the SNF. Furnishing this data will not constitute new burden because it already must be provided per section 1124(a).

5. Question 11 - Trustee

Question 11 asks whether the individual listed in Section A is a trustee of the SNF. We estimate that approximately one percent of SNFs (initials, revalidations, CHOWs) will report a trustee in Section A, requiring them to cite the effective date in Question 11. We project that approximately 5 SNFs per year will report a new or changed trustee via a change of information and thus complete Question 11. We believe the Question 11 data will take the SNF approximately 5 minutes to furnish (or .083 hours). Our estimates are as follows:

TABLE 18: HOUR AND BURDEN ESTIMATES FOR QUESTION 11 - TRUSTEES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	11	.083	1	91.56	92
Form CMS-855A Revalidation Applications	5,167	52	.083	4	91.56	366
Form CMS-855A Change of Ownership Applications	951	10	.083	1	91.56	92
Form CMS-855A Change of Information Applications	5	5	.083	0	91.56	0
Totals	7,178	78	N/A	6	N/A	550

6. Question 12 - Control

Question 12 asks whether the individual listed in Section A exercises direct or indirect operational, managerial, or financial control over the SNF or any part of the SNF. For reasons previously explained concerning Question 10 for Organizations, we will project that “financial control” and “any part thereof” are new/supplemental (and thus new) data elements for which burdens must be estimated.

We project the following:

• Financial control

• Initials/Revalidations/CHOWs – 80 percent of SNFs will report in Section A (per section 1124(c)) a person who exercises financial control over the SNF, hence requiring completion of the Question 10 data.

• Changes of Information – 400 SNFs will report a new or changed financially controlling individual in Section A and accordingly complete Question 10.

• The Question 10 data (excluding the data element concerning parts of the SNF, which is addressed below) will take 12 minutes (0.2 hours) to complete.

• Parts of the SNF

• Initials/Revalidations/CHOWs – It will take the SNF 30 minutes (or 0.5 hours) to disclose the parts of the SNF that the reported individuals control.

• Changes of Information – 3,000 SNFs will report a new or changed individual in Section A and accordingly disclose the parts of the SNF that the person controls with a burden of 3 minutes (or 0.05 hours).

TABLE 19: HOUR AND BURDEN ESTIMATES FOR QUESTION 12 OF SECTION A - CONTROL AND PARTS OF SNF

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Financial Control
Initial Form CMS-855A Applications	1,055	844 *	0.2	169	91.56	15,474
Form CMS-855A Revalidation Applications	5,167	4,134 *	0.2	827	91.56	75,720
Form CMS-855A Change of Ownership Applications	951	761 *	0.2	152	91.56	13,917
Form CMS-855A Change of Information Applications	400	400	0.2	80	91.56	7,325
Totals	7,573	6,139	N/A	1,228	N/A	112,436
Parts of SNF
Initial Form CMS-855A Applications	1,055	1,055	0.5	528	91.56	48,344
Form CMS-855A Revalidation Applications	5,167	5,167	0.5	2,584	91.56	236,591
Form CMS-855A Change of Ownership Applications	951	951	0.5	476	91.56	43,583
Form CMS-855A Change of Information Applications	3,000	3,000	0.05	150	91.56	13,734
Totals	10,173	10,173	N/A	3,738	N/A	342,252
Question 10 Total Burden	17,746	16,312	N/A	4,966	N/A	454,688

(* 80 percent of 1,055; 5,167; and 951, respectively.)

7. Question 13 - Services Provided

Question 13 asks whether the person listed in Section A furnishes any of the services listed in Question 13. The SNF must respond “Yes/No” to each of these bulleted services. If the SNF answers “Yes” to any of them, it must disclose the effective date, the type of services, and whether the services are furnished under contract. As explained in Question 12 of the Organizations section, this represents supplemental data solely for purposes of this information collection request.

We estimate the following:

• Initials/Revalidations/CHOWs - It will take the SNF 45 minutes (or 0.75 hours) to complete this section for its reported individuals.

• Changes of Information - 3,000 SNFs per year will report a new or changed individual in Section A, thus requiring the completion of Question 13 and, if applicable, the furnishing of data regarding the services. The burden will be 5 minutes (.083 minutes).

TABLE 20: HOUR AND BURDEN ESTIMATES FOR QUESTION 13 – SERVICES FURNISHED

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS-855A Applications	1,055	1,055	0.75	791	91.56	72,424
Form CMS-855A Revalidation Applications	5,167	5,167	0.75	3,875	91.56	354,795
Form CMS-855A Change of Ownership Applications	951	951	0.75	713	91.56	65,282
Form CMS-855A Change of Information Applications	3,000	3,000	.083	2,250	91.56	206,010
Totals	10,173	10,173	N/A	7,629	N/A	698,511

8. Question 14 – Leases

Question 14 asks whether the person listed in Section A leases or subleases real property to the SNF. If the SNF responds “Yes,” it must describe the lease arrangement and its type and length, an estimated 20-minute burden (or 0.33 hours). We estimate that 1 percent of SNFs (initials, revalidations, CHOWs) will list an individual in Section A who falls within this category and furnish the requested Question 14 data. We also project that 4 SNFs per year will report a new individual lessor as part of a change of information and provide the Question 12 data. This results in the following burden estimates.

TABLE 21: HOUR AND BURDEN ESTIMATES FOR QUESTION 14 - LEASES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	11	0.33	4	91.56	366
Form CMS-855A Revalidation Applications	5,167	52	0.33	17	91.56	1,557
Form CMS-855A Change of Ownership Applications	951	10	0.33	3	91.56	275
Form CMS-855A	4	4	0.33	1	91.56	92

Change of Information Applications
Totals	7,177	77	N/A	25	N/A	2,290

9. Question 15 – Ownership of SNF Real Property

Question 15 asks whether the individual listed in Section A directly or indirectly owns at least 5 percent of the SNF’s real property or the real property on/in which the SNF operates. We believe that 30 percent of SNFs will report an individual real property owner in Section A and thus further the data in Question 15, a burden of 20 minutes (or 0.33 hours). We further estimate that 50 SNFs per year will report a new or changed real property individual owner as part of a change of information. Our burden projections are as follows:

TABLE 22: HOUR AND BURDEN ESTIMATES FOR QUESTION 15 – REAL PROPERTY

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	317 *	0.33	106	91.56	9,705
Form CMS-855A Revalidation Applications	5,167	1,550*	0.33	517	91.56	47,337
Form CMS-855A Change of Ownership Applications	951	285 *	0.33	95	91.56	8,698
Form CMS-855A Change of Information Applications	50	50	0.33	17	91.56	1,557
Totals	7,223	2,202	N/A	735	N/A	67,297

(* 30 percent of 1,055; 5,167; and 951)

10. Question 16 – SNF Medical Director and Administrator

Question 16 instructs the SNF to check the applicable box if the individual identified in Section A is the SNF’s medical director or administrator. Although SNF medical directors and administrators were not addressed in CMS-6084-F, we included a provision in the CY 2024 Home Health Prospective Payment System Final Rule clarifying that these individuals are considered “managing employees” under 424.502.² This means they must be reported as such on

² Medicare Program; Calendar Year (CY) 2024 Home Health (HH) Prospective Payment System Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin Items and Services; Hospice Informal Dispute Resolution and Special Focus Program Requirements, Certain Requirements for Durable Medical Equipment Prosthetics and Orthotics Supplies; and

the Form CMS-855A. Since SNF managing employees will now be disclosed in the SNF Attachment rather than Section 6, we believe that Question 16 is an appropriate place to capture the SNF’s medical director and administrator.

All SNFs will report this data. It will take the SNF two minutes (or .033 hours) to do. We further estimate that roughly 300 SNFs per year will report a new or changed medical director or administrator as part of a change of information. Our burden estimates are as follows:

TABLE 23: HOUR AND BURDEN ESTIMATES FOR QUESTION 16 – SNF MEDICAL DIRECTORS AND ADMINISTRATORS

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	.033	35	91.56	3,205
Form CMS-855A Revalidation Applications	5,167	5,167	.033	171	91.56	15,657
Form CMS-855A Change of Ownership Applications	951	951	.033	31	91.56	2,838
Form CMS-855A Change of Information Applications	300	300	.033	10	91.56	916
Totals	7,473	7,473	N/A	247	N/A	22,616

11. Additional Disclosable Parties (ADPs) – Questions 17 through 22

Akin to Questions 14 – 18 in the Organizations section of this supporting statement, Questions 17-21 collect data on individuals with an ownership or trustee interest in an ADP. Each question is specific to the ADP’s organization type (e.g., corporation, LLC). We estimate the following:

• Initials/Revalidations/CHOWs: It will take the SNF 45 minutes (or 0.75 hours) to complete Questions 17 through 22 for all its ADPs. All SNFs will report at least one individual ADP.

• Changes of Information – 500 SNFs per year will report a new or changed ADP individual owner/partner/trustee (and/or new/changed data thereon) in Questions 17 – 21. This will be pursuant to: (1) a newly reported ADP; (2) a new or changed owner of an existing ADP; and/or (3) new changed data regarding a current ADP. The burden will be 10 minutes (or

.167 hours)

Provider and Supplier Enrollment Requirements (88 FR 77676).

TABLE 24: HOUR AND BURDEN ESTIMATES FOR QUESTIONS 17 – 21 - ADP OWNERSHIP

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS-855A Applications	1,055	1,055	0.75	791	91.56	72,424
Form CMS- 855A Revalidation Applications	5,167	5,167	0.75	3,875	91.56	354,795
Form CMS- 855A Change of Ownership Applications	951	951	0.75	713	91.56	65,282
Form CMS- 855A Change of Information Applications	500	500	.167	84	91.56	7,691
Totals	7,673	7,673	N/A	5,463	N/A	500,192

Question 22 asks the SNF whether the individual is a corporate officer, corporate director, or LLC member of an ADP. If the SNF answers “Yes,” it must furnish in Question 22: (i) identifying information about the individual; and (ii) description of the membership, effective date, etc. We estimate the following:

• Initials/Revalidations/CHOWs – It will take the SNF 45 minutes to report the information in Question 22 for the ADP corporate officers, corporate directors, and LLC members it discloses.

• Changes of Information – 300 SNFs per year will report a new or changed ADP corporate officer, corporate director, or LLC member. The burden for completing Question 22 with information concerning this person will be 10 minutes (or .167 hours).

TABLE 25: HOUR AND BURDEN ESTIMATES FOR QUESTION 22 – GOVERNING BODY MEMBERS

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	1,055	0.75	791	91.56	72,424

Form CMS-855A Revalidation Applications	5,167	5,167	0.75	3,875	91.56	354,795
Form CMS-855A Change of Ownership Applications	951	951	0.75	713	91.56	65,282
Form CMS-855A Change of Information Applications	300	300	.167	50	91.56	4,578
Totals	7,473	7,473	N/A	5,429	N/A	497,079

12. Owners/Trustees/LLC Managers/Officers/Directors of ADP(s)

Question 23 asks whether the ADP owner/trustee/LLC manager/officer/director (as indicated in Question 17, 18, 19, 20, 21, or 22) has an ownership/trustee/LLC managerial/officer/director interest in the SNF itself or in another ADP of the SNF. If the SNF answers “Yes,” the SNF must list the legal business name of that entity, a burden we estimate to be 20 minutes (or 0.33 hours). We estimate that 20 percent of SNFs (initials, revalidations, CHOWs) will answer “Yes” and list an entity in Question 23. We also project that 100 SNFs per year will report a new or changed entity in Question 23. This results in the following burden estimates.

TABLE 26: HOUR AND BURDEN ESTIMATES FOR QUESTION 23 OF SECTION B –

INTERESTS IN ADPs

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	211 *	0.33	70	91.56	6,409
Form CMS-855A Revalidation Applications	5,167	1,033 *	0.33	341	91.56	31,222
Form CMS-855A Change of Ownership Applications	951	190 *	0.33	63	91.56	5,768
Form CMS-855A Change of Information Applications	100	100	0.33	33	91.56	3,021
Totals	7,273	1,534	N/A	507	N/A	46,420

(* 20 percent of 1,055; 5,167; and 951, respectively.)

3. Section C - Final Adverse Actions

The SNF must disclose whether the individual listed in Section A has had one or more of the adverse actions listed in Section 3 of the CMS-855A imposed against them. SNFs are currently required to submit this data regarding listed in Section 5 of the CMS-855A. Furnishing this

information on the SNF attachment thus will not constitute new burden. We estimate, however, that two percent of SNFs (initials, revalidations, CHOWs) will report at least one entity per section 1124(c) (e.g., an ADP) with an adverse action. We also project that 100 SNFs per year will report a new or changed individual in Section A that has an adverse action. We further estimate that providing this adverse legal action data will take 30 minutes (or 0.5 hours). This results in the following new burden:

TABLE 27: HOUR AND BURDEN ESTIMATES FOR ADVERSE ACTION DATA IN SECTION C

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Form CMS- 855A Applications	1,055	32	0.5	16	91.56	1,465
Form CMS-855A Revalidation Applications	5,167	155	0.5	78	91.56	7,142
Form CMS-855A Change of Ownership Applications	951	29	0.5	15	91.56	1,373
Form CMS-855A Change of Information Applications	100	100	0.5	50	91.56	4,578
Totals	7,273	316	N/A	159	N/A	14,558

TOTALS – CMS-6084-F BURDEN ESTIMATES

Table 28 outlines the total annual burden estimates associated with CMS-6084-F and our requested revisions to the CMS-6084-F.

TABLE 28

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Sections A – C (Organizations)	10,173	10,173	Varies	13,302	91.56	1,217,932
Parent Company Question (Organizations)	10,173	10,173	Varies	647	91.56	59,147
Questions 1 – 7: Relationship to SNF (Organizations)	7,223	768	.167	128	91.56	11,692
Question 9: Trustee (Organizations)	7,178	78	.083	6	91.56	550
Question 10: Control and Parts of SNF (Organizations)	15,746	14,312	Varies	4,866	91.56	445,532
Question 11: Services Provided	8,173	8,173	Varies	4,889	91.56	447,637

(Organizations)
Question 12: Leases (Organizations)	7,223	1,484	0.33	491	91.56	44,956
Question 13: Real Property Ownership (Organizations)	7,473	7,473	0.33	2,491	91.56	228,076
Questions 14 – 18: ADP Ownership (Organizations)	7,673	7,673	Varies	5,463	91.56	500,192
Question 19: Interests in ADPs (Organizations)	7,273	1,534	0.33	507	N/A	46,420
Final Adverse Actions (Organizations)	7,183	153	0.5	78	91.56	7,142
Identifying Data (Individuals) (Section A of Individuals)	10,173	10,173	Varies	15,096	91.56	1,382,190
Questions 1 – 7: Relationship to SNF (Individuals)	10,173	10,173	.067	128	91.56	11,719
Question 9: Governing Body Members (Individuals)	7,673	5,528	Varies	2,599	91.56	237,964
Question 11: Trustee (Individuals)	7,178	78	.083	6	91.56	550
Question 12: Control and Parts of SNF (Individuals)	17,746	16,312	Varies	4,966	91.56	454,688
Question 13: Services Provided (Individuals)	10,173	10,173	Varies	7,629	91.56	698,511
Question 14: Leases (Individuals)	7,177	77	0.33	25	91.56	2,290
Question 15: Real Property Ownership (Individuals)	7,223	2,202	0.33	735	91.56	67,297
Question 16: SNF Medical Director and Administrator	7,473	7,473	.033	247	91.56	22,616
Questions 17 – 21: ADP Ownership (Individuals)	7,673	7,673	Varies	5,463	91.56	500,192
Question 22: ADP Governing/Managing Individuals	7,473	7,473	Varies	5,429	91.56	497,079
Question 23: Interests in ADPs (Individuals)	7,273	1,534	0.33	507	N/A	46,420
Final Adverse Actions (Individuals)	7,273	316	.25	159	91.56	14,558
Totals	202,699	133,706	N/A	75,610	N/A	6,945.350

4. New Hospice Questions in Sections 4 and 6 of the Form CMS-855A

1. Section 4

Section 4 of the Form CMS-855A collects information on the provider’s practice location(s).

We are adding a question exclusive to hospices that asks the hospice to check the provided box if the hospice treats patients at the listed practice location. The question’s purpose is to help identify whether the location is strictly administrative in nature or is one at which services are furnished to patients.

Based on data cited in CMS-1780-F as well as new data, we estimate that each year approximately: (1) 425 hospices initially enroll in Medicare; (2) 1,300 hospices revalidate their enrollment; and (3) 50 additional hospices would have to initially enroll in Medicare due to our new 36-month rule provision in § 424.550(b). All these hospices would have to note in Section 4 whether the listed location at one at which patients are treated. For purposes of this ICR estimate only, we will also project that roughly 150 hospices will report a change in this information. We estimate that it will take the hospice four minutes to furnish this data.

2. Section 6

Section 6 of the Form CMS-855A collects information on the provider’s managing employees. We are adding a data element to Section 6 via which the hospice must identify its administrator and its medical director per the previously mentioned November 13, 2023, HH final rule. We will use the same annual application submission estimates cited in Section 12(e)(1) above (e.g., 425 initial applications), though we will reduce our burden estimates to three minutes.

3. Final Burden Estimates for Section 4 and 6

Table 29 outlines the combined annual burden projections for our additions to Section 4 and 6

TABLE 29 – SECTIONS 4 AND 6: HOSPICES

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits)	Total Cost ($)
Section 4 – Hospice Practice Location
Initial Form CMS-855A Applications	425	425	.067	28	41.56	1,164
Form CMS-855A Revalidation Applications	1,300	1,300	.067	87	41.56	3,616
Form CMS-855A – New Enrollments Per 36-Month Rule	50	50	.067	3	41.56	125
Form CMS-855A Change of Information Applications	150	150	.067	10	41.56	416
Totals	1,925	1,925	N/A	128	N/A	5,321
Section 6 – Hospice Administrator and Medical Director
Initial Form CMS-855A Applications	425	425	.05	21	41.56	873
Form CMS-855A Revalidation Applications	1,300	1,300	.05	65	41.56	2,701
Form CMS-855A – New Enrollments Per 36-Month Rule	50	50	.05	3	41.56	125
Form CMS-855A Change of Information Applications	150	150	.05	8	41.56	332
Totals	1,925	1,925	N/A	97	N/A	4,031
Combined - Burden Questions 4/6 Burden	3,850	3,850	N/A	225	N/A	9,352

13. Cost to Respondents (Capital)

There are no capital costs associated with this collection.

14. Cost to Federal Government

1. MACs

We anticipate additional costs to the MACs with respect to processing the aforementioned: (1) 50 Form CMS-855A initial applications per CMS-1780-F; and (2) information on the revised Form CMS-855A. As shown in Section 15 below, we project a total annual provider burden of 75,985 hours. Given our experience, we estimate it will take the MACs a similar amount of time to process this data.

The applicable MAC hourly is wage equivalent to a GS-9, Step 5 (Washington/Baltimore/Arlington locality), which is $37.15. (See https://www.opm.gov/policy- data-oversight/pay-leave/salaries-wages/salary-tables/24Tables/html/DCB_h.aspx.) This results in an annual MAC cost of $2,822,843 (or 75,985 x $37.15).

2. Federal Government

The cost to the Federal government will mostly involve: (1) the PRA process (e.g., preparing the PRA package); (2) posting the revised form documents to CMS.gov; (3) performing outreach as needed; and (4) responding to inquiries. CMS employees will perform these tasks. The hourly wage of said employee is at a GS-13, Step 5 level (Washington/Baltimore/Arlington locality), or $64.06. (See https://www.opm.gov/policy- data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/DCB_h.pdf.) We estimate that the foregoing tasks will take a total of 150 hours. This results in a total cost of $9,609.

15. Annual Changes in Burden/Program Changes

Pursuant to our changes in CMS-1780-F and the data in Tables 1 and 29, we project the following changes in burden associated with the Form CMS-855A. Burden hours have increased by +75,985 hours as a result of additional requirements associated with 2024 Home Health Prospective Payment System Final Rule (CMS-1780-F), The burden increase is mainly due to the completion of the initial enrollment application rather than the change of ownership form.

Form	Respondents	Total Responses	Total Annual Time (hours)	Total Annual Cost ($)
CMS-855A	+ 206,599	+ 137,606	+ 75,985	+ 6,960,936

16. Publication/Tabulation

Consistent with section 6101(b) of the Affordable Care Act, and as stated in CMS-6084-F, we intend to make data reported per section 1124(c) of the Act publicly available within 1 year after CMS-6084 was published in the Federal Register.

17. Expiration Date

We are planning on displaying the expiration date.

18. Certification Statement

There are no exceptions to the certification statement.

2. Collections of Information Employing Statistical Methods

This collection does not employ statistical methods.

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