National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese)	Form and Instruction	Modified	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese)	Form and Instruction	Modified	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese)	Form and Instruction	Modified	Repair queued
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan)	Form and Instruction	Modified	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish)	Form and Instruction	Modified	Repair queued
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English)	Form and Instruction	Modified	Repair queued
CMS-10105_Supporting_Statement_part_A_.docx	Supporting Statement A	Uploaded 2025-04-29	Repair queued
CMS-10105_Supporting_Statement_part_A_.docx	Supporting Statement A	Uploaded 2025-04-29	Missing upstream
CMS-10105_Supporting_Statement_part_B.docx	Supporting Statement B	Uploaded 2025-04-02	Repair queued
CMS-10105_Supporting_Statement_part_B.docx	Supporting Statement B	Uploaded 2025-04-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (Vietnamese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (Traditional Chinese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (Simplified Chinese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (Samoan)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (Spanish)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Modified	Medicare In-Center Hemodialysis Survey (English)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Other-Sample Cover Letter (English)	Modified

ICR Details

OMB Control No: 0938-0926	ICR Reference No: 202504-0938-001
Status: Historical Active	Previous ICR Reference No: 202207-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/01/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/29/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	36 Months From Approved	09/30/2025
Responses	190,000	0	207,000
Time Burden (Hours)	51,300	0	55,890
Cost Burden (Dollars)	0	0	0

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Abstract: Administration of In-center Hemodialysis CAHPS(ICH CAHPS) survey by more than 5,700 Medicare-certified ESRD facilities is required as part of the value-based purchasing program for payments under the Medicare program, as described in the 2016 proposed and final ESRD Prospective System Payment Update Rules published in the Federal Register on July 1, 2015, and November 6, 2015, respectively. Value-based purchasing promotes CMS’ goals: better healthcare for individuals; better care for populations and communities; and, lower costs through improvement. Beginning in CY2014, ICH facilities are required to contract with a CMS-approved survey vendor to implement the survey; the CMS-approved vendor shall follow a set of standardized survey administration procedures developed for the national implementation. Survey results from the national implementation will be publicly reported on the DFC website on www.medicare.gov.

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Authorizing Statute(s): US Code: 42 USC 1881(h) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 101017	12/13/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 17601	04/28/2025
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
In-Center Hemodialysis CAHPS Survey: National Implementation	CMS-10105, CMS-10105, CMS-10105, CMS-10105, CMS-10105, CMS-10105	Medicare In-Center Hemodialysis Survey (English) ,   Medicare In-Center Hemodialysis Survey (Spanish) ,   Medicare In-Center Hemodialysis Survey (Samoan) ,   Medicare In-Center Hemodialysis Survey (Simplified Chinese) ,   Medicare In-Center Hemodialysis Survey (Traditional Chinese) ,   Medicare In-Center Hemodialysis Survey (Vietnamese)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	190,000	207,000	0	0	-17,000	0
Annual Time Burden (Hours)	51,300	55,890	0	0	-4,590	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: No

Burden Reduction Due to:

Short Statement: The hour burden has decreased from 55,890 in the previous projection to 51,300 due to a decrease in survey response rates.

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Annual Cost to Federal Government: $1,703,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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

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Common Form ICR:  No

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

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

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

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

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

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

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

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

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

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

(v) Nature and extent of confidentiality; and

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

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

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

(j) It makes appropriate use of information technology.

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

Certification Date: 04/29/2025

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