Home Health Agency Cost Report and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-1728-94 Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106 Form	Modified
CMS-1728-94 - Supporting Statement A [rev 09-17-2013 by OSORA PRA].docx Supporting Statement A	2013-09-17

IC Document Collections

IC ID	Document Title	Status
7766	Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106 Form	Modified

ICR Details

OMB Control No: 0938-0022	ICR Reference No: 201309-0938-021
Status: Historical Active	Previous ICR Reference No: 201008-0938-024
Agency/Subagency: HHS/CMS	Agency Tracking No: 20547
Title: Home Health Agency Cost Report and Supporting Regulations
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/2014
	Date Received in OIRA: 09/19/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved	02/28/2014
Responses	11,563	0	7,479
Time Burden (Hours)	2,613,238	0	1,690,254
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1861 Name of Statute: null
   US Code: 42 USC 1395g Name of Law: null
   Statute at Large: 18 Stat. 1815 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 38986	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 57162	09/17/2013
Did the Agency receive public comments on this ICR? No

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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 Certification and Settlement Summary

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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	11,563	7,479	0	0	4,084	0
Annual Time Burden (Hours)	2,613,238	1,690,254	0	0	922,984	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: No

Burden Reduction Due to:

Short Statement: The total burden for the Form CMS-1728-94 is estimated to be 2,613,238 hours and $52,264,760. The changes to the burden are a result of: -The estimated number of respondents increased from 7,479 to 11,563. -The standard rate increased from $15.00 to $20.00 per hour due to a cost of living increase.

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Annual Cost to Federal Government: $6,979,800

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

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Common Form ICR:  No

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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: 09/19/2013

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