(CMS-417) Hospice Request for Certification and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-417 Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20 Form and Instruction	Modified
CMS-417 Supporting Statement Part A 5-15-18.docx Supporting Statement A	2018-05-15

IC Document Collections

IC ID	Document Title	Status
7960	Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0313	ICR Reference No: 201710-0938-010
Status: 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
	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

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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.

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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

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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:
	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

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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

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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	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.

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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

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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: 10/30/2017

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