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OMB Control No: 0938-0746	ICR Reference No: 202302-0938-014
Status: Historical Inactive	Previous ICR Reference No: 202006-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Medicaid Disproportionate Share Hospital (DSH) Annual Reporting Requirements (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: 04/21/2023
	Date Received in OIRA: 03/02/2023
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	09/30/2023	36 Months From Approved	10/31/2023
Responses	51	0	51
Time Burden (Hours)	2,142	0	2,142
Cost Burden (Dollars)	0	0	0

Abstract: For states to receive FFP for DSH payments, federal law requires states to submit an annual independent certified audit, which includes a Data Element Report describing DSH payments made to each DSH hospital. States are responsible for obtaining the independent audit on an annual basis, and providing the auditor and the DSH hospitals subject to audit with instructions on the data elements necessary to ensure compliance. Hospitals in turn must make available the applicable cost and revenue data for auditors, who compile data, then assess and calculate findings. Their work product includes the Data Element Report, supporting documentation, verifications, and other materials as necessary. The Data Element Report must identify each disproportionate share hospital that received a DSH payment adjustment, and provide any other information the Secretary needs to ensure the appropriateness of the payment amount. The annual certified independent audit also includes specific verifications to make sure all DSH payments are appropriate.

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

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-AV00	Proposed rulemaking	88 FR 11865	02/24/2023

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 11865	02/24/2023
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
Data Element Report	CMS-R-266, CMS-R-266	,

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The revision is associated with our February 24, 2023 (88 FR 11865) proposed rule (CMS-2445-P, RIN 0938-AV00) which would require an additional data element to be included as part of the audit report, specifically as an additional element in the Data Element Report, for the quantification of audit findings. The added data element would add 150 hours of burden. We believe this change is a non-substantive change since auditors are already engaged in a focused review of available documentation to quantify the aggregate amounts that comprise each of the existing data elements required under 42 CFR 447.299(c). Outside of and unrelated to the proposed rule we have adjusted our active number of respondents from 51 to 50 as Massachusetts is excluded from the estimated number of respondents as it currently does not complete DSH audits because its entire DSH allotment amount is diverted for payments under a section 1115 demonstration project. The District of Columbia is included in our active estimate and remains as is. At 42 hr/response and 1 response/year, we are adjusting our active time estimate by minus 42 hr.

Annual Cost to Federal Government: $2,360

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

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