View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0022
ICR Reference No:
201602-0938-002
Status:
Historical Active
Previous ICR Reference No:
201309-0938-021
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CMS-1728-94
Title:
Home Health Agency Cost Report and Supporting Regulations
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
06/16/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/11/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2019
36 Months From Approved
02/28/2017
Responses
10,717
0
11,563
Time Burden (Hours)
2,432,759
0
2,613,238
Cost Burden (Dollars)
0
0
0
Abstract:
Form CMS-1728-94 is the form used by Home Health Agencies to report their health care costs to determine the amount of reimbursement for services furnished to Medicare beneficiaries.
Authorizing Statute(s):
US Code:
42 USC 1395g
Statute at Large:
18 Stat. 1815
Statute at Large:
18 Stat. 1861
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
80 FR 53516
09/04/2015
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 7126
02/10/2016
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106
CMS-1728-94
Home Health Agency Cost Report
ICR Summary 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
10,717
11,563
0
-846
0
0
Annual Time Burden (Hours)
2,432,759
2,613,238
0
-180,479
0
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:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
The change in burden from 11,352 in 2014 to 10,717 in 2015 is due to a decrease in the number of respondents. Incorporating the Form CMS-339 into the HHA cost report resulted in an increase in burden of 1 hour for this information collection. The cost per response was changed from $ 20.00 to $ 40.00 to accurately reflect increases in cost of living.
Annual Cost to Federal Government:
$6,855,200
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:
Kayla Williams 410 786-5887 Kayla.Williams@cms.hhs.gov
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:
02/11/2016
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