82 FR 31609 - Agency Information Collection Activities: Submission for OMB Review; Comment Request
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Federal Register Volume 82, Issue 129 (July 7, 2017)
Centers for Medicare & Medicaid Services
Federal Register Volume 82, Issue 129 (July 7, 2017)
| Page Range | 31609-31610 | |
| FR Document | 2017-14230 |
[Federal Register Volume 82, Number 129 (Friday, July 7, 2017)] [Notices] [Pages 31609-31610] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2017-14230] [[Page 31609]] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document Identifiers: CMS-40B, CMS-43, CMS-1763, CMS-10174, CMS-10215, and CMS-R-285] Agency Information Collection Activities: Submission for OMB Review; Comment Request AGENCY: Centers for Medicare & Medicaid Services, HHS. ACTION: Notice. ----------------------------------------------------------------------- SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, and to allow a second opportunity for public comment on the notice. Interested persons are invited to send comments regarding the burden estimate or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected; and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. DATES: Comments on the collection(s) of information must be received by the OMB desk officer by August 7, 2017. ADDRESSES: When commenting on the proposed information collections, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be received by the OMB desk officer via one of the following transmissions: OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax Number: (202) 395-5806 OR Email: [email protected]. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following: 1. Access CMS' Web site address at Web site address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html. 2. Email your request, including your address, phone number, OMB number, and CMS document identifier, to [email protected]. 3. Call the Reports Clearance Office at (410) 786-1326. FOR FURTHER INFORMATION CONTACT: William Parham at (410) 786-4669. SUPPLEMENTARY INFORMATION: Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term ``collection of information'' is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA (44 U.S.C. 3506(c)(2)(A)) requires federal agencies to publish a 30-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension, revision or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice that summarizes the following proposed collection(s) of information for public comment: 1. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Application for Enrollment in Medicare the Medical Insurance Program; Use: The CMS-40B form is used to establish entitlement to and enrollment in supplementary medical insurance for beneficiaries who already have Part A, but not Part B. The form solicits information that is used to determine enrollment for individuals who meet the requirements in section 1836 of the Social Security Act as well as the entitlement of the applicant or a spouse regarding a benefit or annuity paid by the Social Security Administration or the Office of Personnel Management for premium deduction purposes. The Social Security Administration will use the collected information to establish Part B enrollment. Form Number: CMS- 40B (OMB control number: 0938-1230); Frequency: Once; Affected Public: Individuals or households; Number of Respondents: 200,000; Total Annual Responses: 200,000; Total Annual Hours: 50,000. (For policy questions regarding this collection contact Carla Patterson at 410-786-8911.) 2. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease; Use: The CMS-43 application is used (in conjunction with CMS-2728) to establish entitlement to, and enrollment in, Medicare Part A (and Part B) for individuals with end stage renal disease. The application is completed by a Social Security Administration (SSA) claims representative or field representative using information provided by the individual during an interview. The CMS-43 application follows the questions and requirements used by SSA to determine Title II eligibility. This is done not only for consistency purposes, but because certain Title II and Title XVIII insured status and relationship requirements must be met in order to qualify for Medicare under the end stage renal disease provisions. Form Number: CMS-43 (OMB control number: 0938-0800); Frequency: Once; Affected Public: Individuals or households; Number of Respondents: 25,000; Total Annual Responses: 25,000; Total Annual Hours: 10,400. (For policy questions regarding this collection contact Carla Patterson at 410-786-8911.) 3. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Request for Termination of Premium Hospital and Supplementary Medical Insurance; Use: The CMS-1763 form provides us and the Social Security Administration (SSA) with the enrollee's request for termination of Part B, Part A or both Part B and A premium coverage. The form is completed by an SSA claims or field representative using information provided by the Medicare enrollee during an interview. The purpose of the form is to provide to the enrollee with a standardized format to request termination of Part B, Part A premium coverage or both, explain why the enrollee wishes to terminate such coverage, and to acknowledge that the ramifications of the decision are understood. Form Number: CMS-1763 (OMB control number: 0938-0025); Frequency: Once; Affected Public: Individuals or households; Number of Respondents: 101,000; Total Annual Responses: 101,000; Total Annual Hours: 16,867. (For policy questions regarding this collection contact Carla Patterson at 410-786-8911.) 4. Type of Information Collection Request: Reinstatement with change of a previously approved collection; Title of [[Page 31610]] Information Collection: Collection of Prescription Drug Event Data from Contracted Part D Providers for Payment; Use: The collected information is used primarily for payment, but is also used for claim validation as well as for other legislated functions such as quality monitoring, program integrity, and oversight. Form Number: CMS-10174 (OMB control number: 0938-0982); Frequency: Monthly; Affected Public: Business or other for-profits and Not-for-profit institutions; Number of Respondents: 779; Total Annual Responses: 1,409,828,464; Total Annual Hours: 2,820. (For policy questions regarding this collection contact Ivan Iveljic at 410-786-3312.) 5. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Medicaid Payment for Prescription Drugs--Physicians and Hospital Outpatient Departments Collecting and Submitting Drug Identifying Information to State Medicaid Programs; Use: States are required to provide for the collection and submission of utilization data for certain physician-administered drugs in order to receive federal financial participation for these drugs. Physicians, serving as respondents to states, submit National Drug Code numbers and utilization information for ``J'' code physician-administered drugs so that the states will have sufficient information to collect drug rebate dollars. Form Number: CMS-10215 (OMB control number: 0938-1026); Frequency: Weekly; Affected Public: Business or other for-profits and Not-for-profit institutions); Number of Respondents: 20,000; Total Annual Responses: 3,910,000; Total Annual Hours: 16,227. (For policy questions regarding this collection contact Lisa Ferrandi at 410-786- 5445.) 6. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Request for Retirement Benefit Information; Use: Section 1818(d)(5) of the Social Security Act provides that former state and local government employees (who are age 65 or older, have been entitled to Premium Part A for at least 7 years, and did not have the premium paid for by a state, a political subdivision of a state, or an agency or instrumentality of one or more states or political subdivisions) may have the Part A premium reduced to zero. These individuals must also have 10 years of employment with the state or local government employer or a combination of 10 years of employment with a state or local government employer and a non-government employer. The CMS-R-285 form is an essential part of the process of determining whether an individual qualifies for the premium reduction. The Social Security Administration will use this information to help determine whether a beneficiary meets the requirements for reduction of the Part A premium. Form Number: CMS-R-285 (OMB control number: 0938-0769); Frequency: Once; Affected Public: State, Local, or Tribal Governments; Number of Respondents: 500; Total Annual Responses: 500; Total Annual Hours: 125. (For policy questions regarding this collection contact Carla Patterson at 410-786-8911.) Dated: June 30, 2017. William N. Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs. [FR Doc. 2017-14230 Filed 7-6-17; 8:45 am] BILLING CODE 4120-01-P
![Federal Register / Vol. 82, No. 129 / Friday, July 7, 2017 / Notices 31609
DEPARTMENT OF HEALTH AND Guidance/Legislation/Paperwork 2. Type of Information Collection
HUMAN SERVICES ReductionActof1995/PRA-Listing.html. Request: Reinstatement without change
2. Email your request, including your of a previously approved collection;
Centers for Medicare & Medicaid address, phone number, OMB number, Title of Information Collection:
Services and CMS document identifier, to Application for Hospital Insurance
Paperwork@cms.hhs.gov. Benefits for Individuals with End Stage
[Document Identifiers: CMS–40B, CMS–43,
3. Call the Reports Clearance Office at Renal Disease; Use: The CMS–43
CMS–1763, CMS–10174, CMS–10215, and
CMS–R–285] (410) 786–1326. application is used (in conjunction with
FOR FURTHER INFORMATION CONTACT: CMS–2728) to establish entitlement to,
Agency Information Collection William Parham at (410) 786–4669. and enrollment in, Medicare Part A (and
Activities: Submission for OMB SUPPLEMENTARY INFORMATION: Under the Part B) for individuals with end stage
Review; Comment Request Paperwork Reduction Act of 1995 (PRA) renal disease. The application is
(44 U.S.C. 3501–3520), federal agencies completed by a Social Security
AGENCY: Centers for Medicare & Administration (SSA) claims
Medicaid Services, HHS. must obtain approval from the Office of
Management and Budget (OMB) for each representative or field representative
ACTION: Notice. collection of information they conduct using information provided by the
or sponsor. The term ‘‘collection of individual during an interview. The
SUMMARY: The Centers for Medicare & CMS–43 application follows the
Medicaid Services (CMS) is announcing information’’ is defined in 44 U.S.C.
3502(3) and 5 CFR 1320.3(c) and questions and requirements used by
an opportunity for the public to SSA to determine Title II eligibility.
comment on CMS’ intention to collect includes agency requests or
requirements that members of the public This is done not only for consistency
information from the public. Under the purposes, but because certain Title II
Paperwork Reduction Act of 1995 submit reports, keep records, or provide
and Title XVIII insured status and
(PRA), federal agencies are required to information to a third party. Section
relationship requirements must be met
publish notice in the Federal Register 3506(c)(2)(A) of the PRA (44 U.S.C.
in order to qualify for Medicare under
concerning each proposed collection of 3506(c)(2)(A)) requires federal agencies
the end stage renal disease provisions.
information, including each proposed to publish a 30-day notice in the
Form Number: CMS–43 (OMB control
extension or reinstatement of an existing Federal Register concerning each
number: 0938–0800); Frequency: Once;
collection of information, and to allow proposed collection of information,
Affected Public: Individuals or
a second opportunity for public including each proposed extension,
households; Number of Respondents:
comment on the notice. Interested revision or reinstatement of an existing
25,000; Total Annual Responses:
persons are invited to send comments collection of information, before 25,000; Total Annual Hours: 10,400.
regarding the burden estimate or any submitting the collection to OMB for (For policy questions regarding this
other aspect of this collection of approval. To comply with this collection contact Carla Patterson at
information, including the necessity and requirement, CMS is publishing this 410–786–8911.)
utility of the proposed information notice that summarizes the following 3. Type of Information Collection
collection for the proper performance of proposed collection(s) of information for Request: Reinstatement without change
the agency’s functions, the accuracy of public comment: of a previously approved collection;
the estimated burden, ways to enhance 1. Type of Information Collection Title of Information Collection: Request
the quality, utility, and clarity of the Request: Reinstatement without change for Termination of Premium Hospital
information to be collected; and the use of a previously approved collection; and Supplementary Medical Insurance;
of automated collection techniques or Title of Information Collection: Use: The CMS–1763 form provides us
other forms of information technology to Application for Enrollment in Medicare and the Social Security Administration
minimize the information collection the Medical Insurance Program; Use: (SSA) with the enrollee’s request for
burden. The CMS–40B form is used to establish termination of Part B, Part A or both
entitlement to and enrollment in Part B and A premium coverage. The
DATES: Comments on the collection(s) of supplementary medical insurance for form is completed by an SSA claims or
information must be received by the beneficiaries who already have Part A, field representative using information
OMB desk officer by August 7, 2017. but not Part B. The form solicits provided by the Medicare enrollee
ADDRESSES: When commenting on the information that is used to determine during an interview. The purpose of the
proposed information collections, enrollment for individuals who meet the form is to provide to the enrollee with
please reference the document identifier requirements in section 1836 of the a standardized format to request
or OMB control number. To be assured Social Security Act as well as the termination of Part B, Part A premium
consideration, comments and entitlement of the applicant or a spouse coverage or both, explain why the
recommendations must be received by regarding a benefit or annuity paid by enrollee wishes to terminate such
the OMB desk officer via one of the the Social Security Administration or coverage, and to acknowledge that the
following transmissions: OMB, Office of the Office of Personnel Management for ramifications of the decision are
Information and Regulatory Affairs, premium deduction purposes. The understood. Form Number: CMS–1763
Attention: CMS Desk Officer, Fax Social Security Administration will use (OMB control number: 0938–0025);
Number: (202) 395–5806 OR Email: the collected information to establish Frequency: Once; Affected Public:
asabaliauskas on DSKBBXCHB2PROD with NOTICES
OIRA_submission@omb.eop.gov. Part B enrollment. Form Number: CMS– Individuals or households; Number of
To obtain copies of a supporting 40B (OMB control number: 0938–1230); Respondents: 101,000; Total Annual
statement and any related forms for the Frequency: Once; Affected Public: Responses: 101,000; Total Annual
proposed collection(s) summarized in Individuals or households; Number of Hours: 16,867. (For policy questions
this notice, you may make your request Respondents: 200,000; Total Annual regarding this collection contact Carla
using one of following: Responses: 200,000; Total Annual Patterson at 410–786–8911.)
1. Access CMS’ Web site address at Hours: 50,000. (For policy questions 4. Type of Information Collection
Web site address at https:// regarding this collection contact Carla Request: Reinstatement with change of a
www.cms.gov/Regulations-and- Patterson at 410–786–8911.) previously approved collection; Title of
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![31610 Federal Register / Vol. 82, No. 129 / Friday, July 7, 2017 / Notices
Information Collection: Collection of employer and a non-government Appropriations Act, 2017 (Pub. L. 114–
Prescription Drug Event Data from employer. The CMS–R–285 form is an 254).
Contracted Part D Providers for essential part of the process of Justification: Flint, MI, and the
Payment; Use: The collected determining whether an individual surrounding community continues to
information is used primarily for qualifies for the premium reduction. experience ongoing health needs,
payment, but is also used for claim The Social Security Administration will particularly among pregnant women
validation as well as for other legislated use this information to help determine and young children, associated with
functions such as quality monitoring, whether a beneficiary meets the elevated levels of lead in the public
program integrity, and oversight. Form requirements for reduction of the Part A water supply resulting from the city’s
Number: CMS–10174 (OMB control premium. Form Number: CMS–R–285 switch from the Detroit Water Authority
number: 0938–0982); Frequency: (OMB control number: 0938–0769); to the Flint Water Systems between
Monthly; Affected Public: Business or Frequency: Once; Affected Public: State, April 2013 and October 2015.
other for-profits and Not-for-profit Local, or Tribal Governments; Number On January 5, 2016, the state of
institutions; Number of Respondents: of Respondents: 500; Total Annual Michigan declared a state of emergency
779; Total Annual Responses: Responses: 500; Total Annual Hours: for Genesee County, which includes the
1,409,828,464; Total Annual Hours: 125. (For policy questions regarding this city of Flint, authorizing the use of state
2,820. (For policy questions regarding collection contact Carla Patterson at resources to address the public health
this collection contact Ivan Iveljic at 410–786–8911.) crisis created by the elevated levels of
410–786–3312.) lead in the public water system. On
Dated: June 30, 2017. January 16, 2016, a federal emergency
5. Type of Information Collection
Request: Reinstatement without change William N. Parham, III, was declared for the state of Michigan
of a previously approved collection; Director, Paperwork Reduction Staff, Office and authorized federal assistance to
Title of Information Collection: of Strategic Operations and Regulatory provide water, water filters, water filter
Medicaid Payment for Prescription Affairs. cartridges, water test kits, and other
Drugs—Physicians and Hospital [FR Doc. 2017–14230 Filed 7–6–17; 8:45 am] necessary related items.
Outpatient Departments Collecting and BILLING CODE 4120–01–P Prenatal lead exposure can affect
Submitting Drug Identifying Information fertility, the likelihood of miscarriage,
to State Medicaid Programs; Use: States pre-term birth, low birth weight, infant
are required to provide for the collection DEPARTMENT OF HEALTH AND neurodevelopment, and gestational
and submission of utilization data for HUMAN SERVICES hypertension. Of particular concern are
certain physician-administered drugs in the long-term effects in children such as
Health Resources and Services developmental and cognitive delays,
order to receive federal financial
Administration and behavioral disorders. The Healthy
participation for these drugs.
Physicians, serving as respondents to Start program aims to reduce disparities
Notice of Single Source Award to the
states, submit National Drug Code in infant mortality and improve
Genesee County Health Department for
numbers and utilization information for perinatal and child health outcomes. To
Addressing and Preventing Lead
‘‘J’’ code physician-administered drugs advance this mission, the goal of this
Exposure Through Healthy Start in
so that the states will have sufficient program is to minimize developmental
Genesee County, Michigan
information to collect drug rebate delays among lead-exposed children up
dollars. Form Number: CMS–10215 AGENCY: Health Resources and Services to age 6 in Flint and the surrounding
(OMB control number: 0938–1026); Administration, HHS. Genesee County area by connecting
Frequency: Weekly; Affected Public: ACTION: Notice of single source award. them to appropriate screening, services,
Business or other for-profits and Not- and supports.
for-profit institutions); Number of SUMMARY: HRSA announces its intent to Thus, HRSA intends to award a one-
Respondents: 20,000; Total Annual award up to $14,975,000 for a time, single source cooperative
Responses: 3,910,000; Total Annual cooperative agreement to the Genesee agreement to the Genesee County Health
Hours: 16,227. (For policy questions County Health Department, which Department to expedite and strengthen
regarding this collection contact Lisa operates the Genesee County Healthy the ongoing response to address the
Ferrandi at 410–786–5445.) Start program. The purpose of this health effects of lead exposure resulting
6. Type of Information Collection cooperative agreement is to expedite from the Flint, MI, public water supply
Request: Reinstatement without change and strengthen the ongoing response to contamination. This award will enable
of a previously approved collection; address the health effects of lead the Genesee County Health Department
Title of Information Collection: Request exposure resulting from the Flint, MI, to continue to play a vital role in
for Retirement Benefit Information; Use: public water supply contamination. assuring all pregnant women and
Section 1818(d)(5) of the Social Security SUPPLEMENTARY INFORMATION: children impacted by lead
Act provides that former state and local Intended Recipient of the Award: contamination in Genesee County have
government employees (who are age 65 Genesee County Health Department. access to comprehensive health and
or older, have been entitled to Premium Amount of Non-Competitive Awards: social services. With these funds, the
Part A for at least 7 years, and did not Up to $14,975,000. Genesee County Health Department will
have the premium paid for by a state, a Period of Funding: July 1, 2017–June leverage its existing Healthy Start
asabaliauskas on DSKBBXCHB2PROD with NOTICES
political subdivision of a state, or an 30, 2022. infrastructure and in-depth
agency or instrumentality of one or CFDA Number: 93.926. understanding of the maternal and child
more states or political subdivisions) Authority: Water Infrastructure population in Genesee County to assess,
may have the Part A premium reduced Improvements for the Nation (WIIN) Act mitigate, and provide consultation to
to zero. These individuals must also (Pub. L. 114–322); Section 330H of the pregnant women and children up to age
have 10 years of employment with the Public Health Service Act (42 U.S.C. 6 that may be impacted by lead
state or local government employer or a 254c–8), as amended by Public Law exposure during the Flint water crisis.
combination of 10 years of employment 110–339, Section 2; and Further Activities under this award include
with a state or local government Continuing and Security Assistance identifying children in Flint and the
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Document Created: 2017-07-07 02:19:36
Document Modified: 2017-07-07 02:19:36
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice. | |
| Dates | Comments on the collection(s) of information must be received by the OMB desk officer by August 7, 2017. | |
| Contact | William Parham at (410) 786-4669. | |
| FR Citation | 82 FR 31609 |
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