View Information Collection Request (ICR) Package
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Certification
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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:
0938-0313
ICR Reference No:
201710-0938-010
Status:
Historical Active
Previous ICR Reference No:
201401-0938-017
Agency/Subagency:
HHS/CMS
Agency Tracking No:
21373
Title:
(CMS-417) Hospice Request for Certification and Supporting Regulations
Type of Information Collection:
Reinstatement without change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
05/18/2018
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/30/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2021
36 Months From Approved
Responses
851
0
0
Time Burden (Hours)
213
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.
Authorizing Statute(s):
US Code:
42 USC 418
Name of Law: Hospice Care
PL:
Pub.L. 97 - 248 1861
Name of Law: Social Security Act
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:
82 FR 37097
08/08/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 49611
10/26/2017
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
Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20
CMS-417
Hospice Request for Certification in the Medicare Program
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
851
0
0
0
-317
1,168
Annual Time Burden (Hours)
213
0
0
0
-79
292
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:
No
Burden Reduction Due to:
Short Statement:
In this document, we estimate that one third of the 2,554 non-accredited hospices (CY 2016) will be impacted, or 851 non-accredited hospices. Previously, we estimated that 1,168 hospices would complete the form; we reached this estimate by starting with the number of standard surveys in FY 2013 (847) and then adding 321 initial surveys. However, as initial surveys are a subset of standard surveys, a more accurate estimate need not include this subset. Thus in our current estimate, the burden figures have changed. The estimated hourly burden has decreased from 292 hours to 213 hours per year.
Annual Cost to Federal Government:
$0
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?
Uncollected
Agency Contact:
Denise King 410 786-1013 Denise.King@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:
10/30/2017
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