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

Forms and Documents

Document Name	Status
Form CMS-10870 Rural Emergency Hospital Quality Reporting (REHQR) Program Form and Instruction	Modified
CMS-10870_REHQR CY 2026 Supporting Statement Part B.docx Supporting Statement B	2025-08-19
CMS-10870_REHQR CY 2026 Supporting Statement Part A.docx Supporting Statement A	2025-08-19
CY 2026 PR REHQR Reg Text Crosswalk.docx Supplementary Document	2025-08-19

IC Document Collections

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

ICR Details

OMB Control No: 0938-1454	ICR Reference No: 202508-0938-012
Status: Historical Inactive	Previous ICR Reference No: 202412-0938-021
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
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 09/20/2025
	Date Received in OIRA: 08/20/2025
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	36 Months From Approved	12/31/2026
Responses	4,356	0	4,356
Time Burden (Hours)	8,579	0	8,579
Cost Burden (Dollars)	0	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): US Code: 42 USC 1395x Name of Law: Social Security Act
   PL: Pub.L. 116 - 260 125 Name of Law: Consolidated Appropriations Act of 2021
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV51	Proposed rulemaking	90 FR 33476	07/17/2025

---

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

---

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: Miscellaneous Actions

Short Statement: Burden has decreased due to the proposed removal of the Hospital Commitment to Health Equity (HCHE), the Screening for Social Drivers of Health (SDOH), and the Screen Positive Rate for SDOH measures, as well as the proposed adoption of the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM).

---

Annual Cost to Federal Government: $10,227,655

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: 08/20/2025

---