Independent Rural Health Clinic Cost Report (CMS-222-17)

Forms and Documents

Document	Type	Status	Availability
CMS 222-17 Supporting Statement.docx	Supporting Statement A	Uploaded 2024-10-02	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
7853	Rural Health Clinic Cost Report (CMS-222-17)	Instruction	Modified

ICR Details

OMB Control No: 0938-0107	ICR Reference No: 202410-0938-004
Status: Received in OIRA	Previous ICR Reference No: 202112-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Independent Rural Health Clinic Cost Report (CMS-222-17)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/17/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2025
Responses	2,101	1,724
Time Burden (Hours)	115,555	94,820
Cost Burden (Dollars)	0	0

---

Abstract: The Form CMS-222-17 cost report is needed to determine program reimbursement and the amount of reasonable cost due to providers for furnishing medical services to Medicare beneficiaries.

---

Authorizing Statute(s): US Code: 42 USC 1395g Name of Law: Payment to Providers of services
   US Code: 42 USC 1395h Name of Law: Provisions relating to the administration of Part A
   US Code: 42 USC 1395i Name of Law: Payment of Benefits
   US Code: 42 USC 1395x Name of Law: Definitions of services, Institutions, etc
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56754	07/10/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 76113	09/17/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Rural Health Clinic Cost Report (CMS-222-17)	222-17	Rural Health Clinic Cost Report

---

ICR Summary 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	2,101	1,724	0	377	0	0
Annual Time Burden (Hours)	115,555	94,820	0	20,735	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: There is an increase in burden due to an anticipated increase in responding rural health clinics.

---

Annual Cost to Federal Government: $2,703,551

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

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/17/2024

---