The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Survey Mode Experiment (CMS-10105)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (English)	Form and Instruction	New	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese)	Form and Instruction	Unchanged	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese)	Form and Instruction	Unchanged	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese)	Form and Instruction	Unchanged	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan)	Form and Instruction	Unchanged	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish)	Form and Instruction	Unchanged	Available
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English)	Form and Instruction	Unchanged	Available
Public Comment - Center for the Study of Services.pdf	Public Comments	Uploaded 2026-11-06	Available
Mayo.edu.pdf	Public Comments	Uploaded 2026-11-06	Available
Response to Comment on ICH CAHPS Mode Experiment package_10.13.26.docx	Supplementary Document	Uploaded 2026-11-06	Available
Survey-Crosswalk-Current-vs-ICH-Home-508_RevNov2026.pdf	Supplementary Document	Uploaded 2026-11-06	Available
CMS-10105_ICH-CAHPS-ModeExperiment-Supporting_Statement_part_B_.docx	Supporting Statement B	Uploaded 2026-11-06	Available
CMS-10105_ICH CAHPS Mode Experiment_Supporting_Statement_part_A.docx	Supporting Statement A	Uploaded 2026-11-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
283621	Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey	Form and Instruction	New	Medicare In-Center and Home Dialysis Survey (Spanish)
283621	Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey	Form and Instruction	New	Medicare In-Center and Home Dialysis Survey (English)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (Vietnamese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (Traditional Chinese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (Simplified Chinese)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (Samoan)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (Spanish)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction	Unchanged	Medicare In-Center Hemodialysis Survey (English)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Other-Sample Cover Letter (English)	Unchanged

ICR Details

OMB Control No: 0938-0926	ICR Reference No: 202611-0938-008
Status: Received in OIRA	Previous ICR Reference No: 202509-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Survey Mode Experiment (CMS-10105)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/06/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2029
Responses	211,770	207,500
Time Burden (Hours)	42,269	41,500
Cost Burden (Dollars)	0	0

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Abstract: CMS designed the ICH CAHPS survey and measures to enable dialysis patients to make more informed decisions when choosing a dialysis facility, to aid facilities in their quality improvement efforts, and to help CMS monitor the performance of dialysis facilities. CMS publicly reports clinical quality measures and patient experience of care survey results for kidney dialysis centers on Care Compare on Medicare.gov. Public reporting of ICH CAHPS data is refreshed in April and October, with each refresh including a rolling average of the two most recent survey periods available. Both clinical and patient experience of care quality measures enable patients with end-stage renal disease (ESRD) to make informed decisions when choosing a dialysis facility. The ICH CAHPS survey fulfills a requirement of the ESRD Quality Incentive Program (QIP).

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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:
	91 FR 45818	07/21/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 69848	11/05/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

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)
Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey	CMS-10105, CMS-10105	Medicare In-Center and Home Dialysis Survey (English) ,   Medicare In-Center and Home Dialysis Survey (Spanish)

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ICR Summary of Burden

table that charts list 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	211,770	207,500	0	4,270	0	0
Annual Time Burden (Hours)	42,269	41,500	0	769	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: The current annualized burden for the national implementation of the ICH CAHPS Survey is 41,500 hours. Adding the one-time mode experiment to the national implementation data collection, which is estimated at 768.6 hours, increases the annualized hour burden to 42,268.6 hours.

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Annual Cost to Federal Government: $2,392,000

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: 11/06/2026

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