Independent Renal Dialysis Facility Cost Report (CMS-265-11)

Forms and Documents

Document Name	Status
r6P242 Supporting Statement A.docx Supporting Statement A	2022-05-05
r6P242 Crosswalk.pdf Supplementary Document	2022-05-03

IC Document Collections

IC ID	Document Title	Status
7893	Renal Dialysis Facility Cost Report Instruction	Modified

ICR Details

OMB Control No: 0938-0236	ICR Reference No: 202205-0938-001
Status: Received in OIRA	Previous ICR Reference No: 201709-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Independent Renal Dialysis Facility Cost Report (CMS-265-11)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/05/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	7,492	0
Time Burden (Hours)	494,472	0
Cost Burden (Dollars)	0	0

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Abstract: CMS requires the Form CMS-265-11 to determine an ESRD facility’s reasonable costs incurred in furnishing medical services to Medicare beneficiaries. ESRD facilities paid under the ESRD prospective payment system (PPS) may receive reimbursement in addition to the ESRD PPS payment for Medicare reimbursable bad debts. CMS uses the Form 265-11 for annual rate setting; payment refinement activities, including developing a ESRD market basket; and Medicare Trust Fund projections; and to support program operations. Additionally, the Medicare Payment Advisory Commission (MedPAC) uses the cost report data to calculate Medicare margins (a measure of the relationship between Medicare’s payments and providers’ Medicare costs) and analyze data to formulate Medicare Program recommendations to Congress.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 153 Name of Law: Medicare Improvements for Patients and Providers Act
   US Code: 42 USC 1395g Name of Law: Payment of Providers of Services
  

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:
	87 FR 9627	02/22/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 26760	05/05/2022
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
Renal Dialysis Facility Cost Report	CMS-265-11	Renal Dialysis Facility Cost Report

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ICR Summary of Burden

	Total Request	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	7,492	0	0	671	0	6,821
Annual Time Burden (Hours)	494,472	0	0	51,107	0	443,365
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: An increase in the number of respondents by 671 (from 6,821 in 2017 to 7,492 in 2021), the net result of new ESRD facilities certified to participate in the Medicare program and existing ESRD facilities terminated from the Medicare program; An increase in the burden hours from 65 in 2017 to 66 in 2021 due to the proposed Worksheet A-7.

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Annual Cost to Federal Government: $30,013,098

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: 05/05/2022

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