Information Collection Request

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

ICR 202504-0938-001 · OMB 0938-0926 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
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 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (Vietnamese)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (Traditional Chinese)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (Simplified Chinese)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (Samoan)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (Spanish)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction ModifiedMedicare In-Center Hemodialysis Survey (English)
207671 In-Center Hemodialysis CAHPS Survey: National Implementation Other-Sample Cover Letter (English) Modified
ICR Details
0938-0926 202504-0938-001
Historical Active 202207-0938-007
HHS/CMS CM-CPC
National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)
Extension without change of a currently approved collection   No
Regular
Approved without change 07/01/2025
Retrieve Notice of Action (NOA) 04/29/2025
  Inventory as of this Action Requested Previously Approved
01/31/2026 36 Months From Approved 09/30/2025
190,000 0 207,000
51,300 0 55,890
0 0 0

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.

US Code: 42 USC 1881(h) Name of Law: Social Security Act
  
None

Not associated with rulemaking

  89 FR 101017 12/13/2024
90 FR 17601 04/28/2025
No

  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
No
No
The hour burden has decreased from 55,890 in the previous projection to 51,300 due to a decrease in survey response rates.

$1,703,000
Yes Part B of Supporting Statement
    No
    No
Yes
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/29/2025