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:
0938-0236
ICR Reference No:
202205-0938-001
Status:
Active
Previous ICR Reference No:
201709-0938-009
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CM-FFS
Title:
Independent Renal Dialysis Facility Cost Report (CMS-265-11)
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
10/17/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/05/2022
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2025
36 Months From Approved
Responses
7,541
0
0
Time Burden (Hours)
497,706
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
CMS requires the Form CMS-265-11 to determine an ESRD facility’s reasonable costs incurred in furnishing medical services to Medicare beneficiaries. ESRD facilities paid under the ESRD prospective payment system (PPS) may receive reimbursement in addition to the ESRD PPS payment for Medicare reimbursable bad debts. CMS uses the Form 265-11 for annual rate setting; payment refinement activities, including developing a ESRD market basket; and Medicare Trust Fund projections; and to support program operations. Additionally, the Medicare Payment Advisory Commission (MedPAC) uses the cost report data to calculate Medicare margins (a measure of the relationship between Medicare’s payments and providers’ Medicare costs) and analyze data to formulate Medicare Program recommendations to Congress.
Authorizing Statute(s):
PL:
Pub.L. 110 - 275 153
Name of Law: Medicare Improvements for Patients and Providers Act
US Code:
42 USC 1395g
Name of Law: Payment of Providers of Services
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:
87 FR 9627
02/22/2022
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 26760
05/05/2022
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
Renal Dialysis Facility Cost Report
CMS-265-11
Renal Dialysis Facility 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
7,541
0
0
0
720
6,821
Annual Time Burden (Hours)
497,706
0
0
0
54,341
443,365
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:
An increase in the number of respondents by 720 (from 6,821 in 2017 to 7,541 in 2022), the net result of new ESRD facilities certified to participate in the Medicare program and existing ESRD facilities terminated from the Medicare program; An increase in the burden hours from 65 in 2017 to 66 in 2021 due to the proposed Worksheet A-7.
Annual Cost to Federal Government:
$30,209,106
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
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@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:
05/05/2022
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