Medicaid Disproportionate Share Hospital Annual Reporting (CMS-R-266)

Forms and Documents

Document Name	Status
Form CMS-R-266 Medicaid Disproportionate Share Hospital (DSH) Annual Report Form	Modified
CMS-R-266 -Supporting Statement A (2020 version 3).docx Supporting Statement A	2020-06-05

IC Document Collections

IC ID	Document Title	Status
8445	Medicaid Disproportionate Share Hospital (DSH) Annual Report Form	Modified

ICR Details

OMB Control No: 0938-0746	ICR Reference No: 202006-0938-002
Status: Active	Previous ICR Reference No: 201703-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Medicaid Disproportionate Share Hospital Annual Reporting (CMS-R-266)
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: 09/18/2020
	Date Received in OIRA: 06/05/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2023	36 Months From Approved	09/30/2020
Responses	51	0	51
Time Burden (Hours)	2,142	0	2,142
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1923(a)(2)(D) of the Act requires the States to submit an annual report that identifies each DHS payment under the State's Medicaid program in the preceding fiscal year and the amount of DSH payments paid to that hospital in the same year and such other information as the Secretary determines necessary to ensure the appropriateness of DHS payments. The information supplied will satisfy the requirements under section 1923(a)(2)(D) of the Act as well.

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

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 1001 Name of Law: Medicare Modernization Act

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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:
	84 FR 63722	11/18/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 34449	06/04/2020
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
Medicaid Disproportionate Share Hospital (DSH) Annual Report	CMS-R-266	Disproportionate Share Hospital (DSH) Annual Report

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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	51	51	0	0	0	0
Annual Time Burden (Hours)	2,142	2,142	0	0	0	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:

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Annual Cost to Federal Government: $920

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

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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: 06/05/2020

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