Medicare Rural Hospital Flexibility Grant Program Performance Measures

Forms and Documents

Document Name	Status
Form A Medicare Rural Hospital Flexibility Grant Program Performance Measures Form	Modified
Supporting Statement A - 0915-0363 - FORHP - 09102025.docx Supporting Statement A	2025-09-22

IC Document Collections

IC ID	Document Title	Status
206758	Medicare Rural Hospital Flexibility Grant Program Performance Measures Form	Modified

ICR Details

OMB Control No: 0915-0363	ICR Reference No: 202509-0915-003
Status: Received in OIRA	Previous ICR Reference No: 202208-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 19326
Title: Medicare Rural Hospital Flexibility Grant Program Performance Measures
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/22/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2025
Responses	45	45
Time Burden (Hours)	2,475	3,150
Cost Burden (Dollars)	0	0

---

Abstract: The Flex Program enables state designated entities to support critical access hospitals (CAHs) in quality improvement, quality reporting, performance improvement, and benchmarking; to assist facilities seeking designation as critical access hospitals; and to create a program to establish or expand the provision of rural emergency medical services (EMS). These initiatives are meant to ensure residents in rural communities have access to high quality health care services. These initiatives cover the following program areas: quality improvement; financial and operational improvement; population health and EMS improvement; critical access hospital (CAH) conversion; and integration of innovative care models. Flex program performance measures were developed with stakeholder feedback to provide aggregate program data required by Congress under the Government Performance and Results Modernization Act of 2010. The information collected is used for identifying and understanding programmatic improvement across program areas, as well as guiding future iterations of the Flex Program and prioritizing areas of need and support.

---

Authorizing Statute(s): PL: Pub.L. 111 - 352 2142 Name of Law: GPRA Modernization Act of 2010
   US Code: 42 USC 912 Name of Law: Office of Rural Health Policy
   US Code: 42 USC 1395i-4 Name of Law: Medicare rural hospital flexibility program
  

Citations for New Statutory Requirements: None

---

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:
	89 FR 88053	11/06/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 45388	09/22/2025
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Rural Hospital Flexibility Grant Program Performance Measures	A, B	Flex Program Areas and Outcome Measures ,   U2W Flex Program Sample Data Collection

---

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	45	45	0	0	0	0
Annual Time Burden (Hours)	2,475	3,150	0	-675	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated burden per respondent is based on an average of the time needed for completion. This was determined by current respondents to this submission providing the amount of time it would take for them to complete a form in this manner. Different respondents were engaged and this number represents the average of those times. This is a decrease in the estimated burden hours from the previous ICR, as information will be consolidated into one location, rather than entities needing to maintain data in multiple locations to report back to HRSA.

---

Annual Cost to Federal Government: $236,264

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

---

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: 09/22/2025

---