Rural Emergency Hospital Quality Reporting (REHQR) (CMS-10870)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10870 Rural Emergency Hospital Quality Reporting (REHQR) Program	Form and Instruction	Modified	Repair queued
REHQR CY 2025 Supporting Statement Part A (final rule).docx	Supporting Statement A	Uploaded 2025-01-06	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
262060	Rural Emergency Hospital Quality Reporting (REHQR) Program	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1454	ICR Reference No: 202412-0938-021
Status: Received in OIRA	Previous ICR Reference No: 202410-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Rural Emergency Hospital Quality Reporting (REHQR) (CMS-10870)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/10/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2027
Responses	4,356	187,992
Time Burden (Hours)	8,579	9,101
Cost Burden (Dollars)	0	0

---

Abstract: The Consolidated Appropriations Act (CAA), 2021, was signed into law in December 2020. In this legislation, Congress established a new Medicare provider type: Rural Emergency Hospitals (REHs). Section 125 of Division CC of the CAA, 2021 added section 1861(kkk) to the Social Security Act (the Act). This section defines an REH as a facility that, in relevant part, was as of December 27, 2020: (1) a Critical Access Hospital (CAH) or a subsection (d) hospital with not more than 50 beds located in a county (or equivalent unit of local government) in a rural area (defined in section 1886(d)(2)(D) of the Act); or (2) was a subsection (d) hospital with not more than 50 beds that was treated as being in a rural area pursuant to section 1886(d)(8)(E) of the Act. Under section 1861(kkk)(7) of the Act, as added by section 125 of Division CC of the CAA, 2021, the Secretary is required to establish quality measurement reporting requirements for REHs, which may include the use of a small number of claims-based measures or patient experience surveys. An REH must submit quality measure data to the Secretary, and the Secretary shall establish procedures to make the data available to the public on a CMS website.

---

Authorizing Statute(s): PL: Pub.L. 116 - 260 125 Name of Law: Consolidated Appropriations Act of 2021
   US Code: 42 USC 1395x Name of Law: Social Security Act
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 260 125 Name of Law: Consolidated Appropriations Act of 2021
US Code: 42 USC 1395x Name of Law: Social Security Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV35	Final or interim final rulemaking	89 FR 93912	11/27/2024

---

Federal Register Notices & Comments

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 Emergency Hospital Quality Reporting (REHQR) Program	CMS-10870	Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form

---

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	4,356	187,992	0	-183,636	0	0
Annual Time Burden (Hours)	8,579	9,101	0	-522	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: The adoption of the HCHE measure results in a total estimated burden increase of six hours at a cost of $332 beginning with the CY 2027 program determination. The adoption of the Screening for SDOH and Screen Positive Rate for SDOH measures results in a total estimated burden increase of 12,984 hours at a cost of $318,163 and six hours at a cost of $332, respectively, when mandatory reporting begins for the CY 2028 program determination. Accounting for the impact of the measure adoptions in the CY 2025 OPPS/ASC final rule, our updated estimate of the number of REHs results in an annual burden decrease of 8,698 hours and $452,026 through the CY 2028 payment determination. From the CY 2027 payment determination through the CY 2028 program determination, due to these measure adoptions and adjustments, the aggregate increase in burden hours is 4,298 hours (-8,698 + 6 + 12,984 + 6) with a decrease of $133,199 (-$452,026 + $332 + $318,163 + $332) as shown in Tables 4 and 5.

---

Annual Cost to Federal Government: $10,223,800

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: 01/10/2025

---