Home Health Change of Care Notice (HHCCN) (CMS-10280)

Forms and Documents

Document Name	Status
Form CMS-10280 Home Health Change of Care Notice (HHCCN) Form	Modified
CMS-10280 - Supporting Statement A - Passback_Clean.docx Supporting Statement A	2016-05-26

IC Document Collections

IC ID	Document Title	Status
206099	Home Health Change of Care Notice (HHCCN) Form	Modified

ICR Details

OMB Control No: 0938-1196	ICR Reference No: 201604-0938-004
Status: Historical Active	Previous ICR Reference No: 201303-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Home Health Change of Care Notice (HHCCN) (CMS-10280)
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: 06/08/2016
	Date Received in OIRA: 04/11/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	06/30/2016
Responses	13,764,434	0	14,126,428
Time Burden (Hours)	916,711	0	941,385
Cost Burden (Dollars)	0	0	0

---

Abstract: Home health agencies (HHAs) are required to provide written notice to original Medicare beneficiaries under various circumstances involving the initiation, reduction, or termination of services consistent with Home Health Agencies Conditions of Participation (COPs) as set forth in section 1891 of the Social Security Act (the Act) and subsequent to the decision of the US Court of Appeals (2nd Circuit) in Lutwin v. Thompson. The notice used to fulfill these requirements is the HHCCN.

---

Authorizing Statute(s): US Code: 42 USC 1395bbb Name of Law: CONDITIONS OF PARTICIPATION FOR HOME HEALTH AGENCIES; HOME HEALTH QUALITY
  

Citations for New Statutory Requirements: US Code: 42 USC 1395bbb Name of Law: CONDITIONS OF PARTICIPATION FOR HOME HEALTH AGENCIES; HOME HEALTH QUALITY

---

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 65228	10/26/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 12903	03/11/2016
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
Home Health Change of Care Notice (HHCCN)	CMS-10280, CMS-10280	Home Health Change of Care Notice (HHCCN) ,   Aviso de Cambio del Cuidado de la Salud en el Hogar (HHCCN)

---

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	13,764,434	14,126,428	0	0	-361,994	0
Annual Time Burden (Hours)	916,711	941,385	0	0	-24,674	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 HHCCN has been minimally changed with this submission to include language informing beneficiaries of their rights under Section 504 of the Rehabilitation Act of 1973 (Section 504) by alerting the beneficiary to CMS’s nondiscrimination practices and the availability of alternate forms of this notice if needed. There are no substantive changes to this form. There are minor changes to the form instructions. The number of HHCCNs delivered annually is estimated to be 13,764,434. The number of HHCCNs delivered annually in the 2013 submission for this collection was 14,126,428, which decreased by 361,994 HHCCNs. The annual hour burden associated with this collection is estimated to be 916,711 hours. The annual hour burden associated in the 2013 submission for this collection was 941,385 hours which decreases the annual hour burden by 24,674. The 176,755 decrease in the burden estimates is likely due to a decrease in the annual number of home health episodes (from 6,897,670 to 6,720,915) which would cause a decrease in the number of HHCCNs issued annually per respondent.

---

Annual Cost to Federal Government: $0

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

---

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: 04/11/2016

---