Federally Qualified Health Center Cost Report Form (CMS-224-14)

Forms and Documents

Document	Type	Status	Availability
Form 224-14 Federally Qualified Health Center Cost Report Form	Form	Modified	Repair queued
CMS-224-14. Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2025-01-14	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
217774	Federally Qualified Health Center Cost Report Form	Form	Modified

ICR Details

OMB Control No: 0938-1298	ICR Reference No: 202412-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202206-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Federally Qualified Health Center Cost Report Form (CMS-224-14)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/14/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2025
Responses	2,967	2,890
Time Burden (Hours)	172,086	167,620
Cost Burden (Dollars)	0	0

---

Abstract: Providers of services participating in the Medicare program are required under sections 1815(a) and 1861(v)(1)(A) of the Act (42 U.S.C. 1395g) to submit annual information to achieve settlement of costs for health care services rendered to Medicare beneficiaries. In addition, regulations at 42 CFR 413.20 and 413.24 require adequate cost data and cost reports from providers on an annual basis. The form CMS-224-14 cost report is needed to determine a provider's reasonable costs incurred in furnishing medical services to Medicare beneficiaries and reimbursement due to or from a provider.

---

Authorizing Statute(s): US Code: 42 USC 1395g Name of Law: Social Security Act
   PL: Pub.L. 111 - 148 10501(i)(3)(A) Name of Law: Affordable Care Act
  

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 79612	09/30/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 97619	12/09/2024
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
Federally Qualified Health Center Cost Report Form	224-14	Federally Qualified Health Center 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	2,967	2,890	0	77	0	0
Annual Time Burden (Hours)	172,086	167,620	0	4,466	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: Burden has increased due to an increased number of expected respondents.

---

Annual Cost to Federal Government: $3,735,022

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]? Yes

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: 01/14/2025

---