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OMB Control No: 0938-0746	ICR Reference No: 201306-0938-008
Status: Historical Inactive	Previous ICR Reference No: 201104-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 19726
Title: Medicaid Disproportionate Share Hospital Annual Reporting (CMS-R-266)
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: 01/27/2014
	Date Received in OIRA: 06/18/2013
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	05/31/2014	36 Months From Approved	05/31/2014
Responses	52	0	52
Time Burden (Hours)	1,976	0	1,976
Cost Burden (Dollars)	0	0	0

Abstract: Section 1923(a)(2)(D) of the Act requires the States to submit an annual report that identifies each DHS payment under the State's Medicaid program in the preceding fiscal year and the amount of DSH payments paid to that hospital in the same year and such other information as the Secretary determines necessary to ensure the appropriateness of DHS payments. The information supplied will satisfy the requirements under section 1923(a)(2)(D) of the Act as well.

Authorizing Statute(s): Statute at Large: 19 Stat. 1923
PL: Pub.L. 108 - 173 1001 Name of Law: Medicare Modernization Act

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 1001 Name of Law: Medicare Modernization Act

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR31	Proposed rulemaking	78 FR 28551	05/15/2013

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 28551	05/15/2013
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
Medicaid Disproportionate Share Hospital Annual Reporting	CMS-R-266

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: There are proposed changes to the burden based on the a notice of proposed rulemaking (CMS-2367-P) that would require the submission of additional information under section 1923(j)(1) of the Social Security Act. To ensure the most accurate burden estimate, there are changes to the hours and wages based on our review of State submissions under section 1923(j) of the Social Security Act. Additionally, the number of respondents has been corrected from 52 to 51 (all 50 states and the District of Columbia). Hours The information submitted by each State is required annually, beginning at the end of the first quarter of the fiscal year following the reporting period. The notice of proposed rulemaking (CMS-2367-P) would require additional information hospital specific payment data from States related to the disproportionate share hospital program. We estimate that it would take an additional 4 hours per state (from 38 approved hr to 42 total hr) to complete the DSH reporting spreadsheets. Wages We used the following hourly labor rates and estimated the time to complete each task: $51.00/hr and an additional 102 hr (1,071 total hours) for management and professional staff to review and prepare reports, and $28.77/hr and an additional 102 hr (1,071 total hours) for office staff to prepare the reports. We estimate that the proposed changes will require an additional cost of $10,404 (or $85,434 total) based on the additional 204 (4 x 51) annual hours for all states and the District of Columbia (or 2,142 total hr).

Annual Cost to Federal Government: $825

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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