[Federal Register Volume 78, Number 120 (Friday, June 21, 2013)]
[Notices]
[Pages 37542-37545]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-14878]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifiers: CMS-10116, CMS-R-245, CMS-1572, CMS-250-254, 
CMS-379, CMS-4040, CMS-10174, CMS-10261, and CMS-R-285]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare & Medicaid Services, HHS.

ACTION: Notice.

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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

[[Page 37543]]

extension or reinstatement of an existing collection of information) 
and to allow 60 days for public comment on the proposed action. 
Interested persons are invited to send comments regarding our burden 
estimates or any other aspect of this collection of information, 
including any of the following subjects: (1) The necessity and utility 
of the proposed information collection for the proper performance of 
the agency's functions; (2) the accuracy of the estimated burden; (3) 
ways to enhance the quality, utility, and clarity of the information to 
be collected; and (4) the use of automated collection techniques or 
other forms of information technology to minimize the information 
collection burden.

DATES: Comments must be received by August 20, 2013.

ADDRESSES: When commenting, please reference the document identifier or 
OMB control number (OCN). To be assured consideration, comments and 
recommendations must be submitted in any one of the following ways:
    1. Electronically. You may send your comments electronically to 
http://www.regulations.gov. Follow the instructions for ``Comment or 
Submission'' or ``More Search Options'' to find the information 
collection document(s) that are accepting comments.
    2. By regular mail. You may mail written comments to the following 
address: CMS, Office of Strategic Operations and Regulatory Affairs, 
Division of Regulations Development, Attention: Document Identifier/OMB 
Control Number ------, Room C4-26-05, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850.
    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 http://www.cms.hhs.gov/PaperworkReductionActof1995.
    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: Reports Clearance Office at (410) 786-
1326.

SUPPLEMENTARY INFORMATION: This notice sets out a summary of the use 
and burden associated with the following information collections. More 
detailed information can be found in each collection's supporting 
statement and associated materials (see ADDRESSES).
    CMS-10116 Conditions for Payment of Power Mobility Devices, 
including Power Wheelchairs and Power-Operated Vehicles.
    CMS-R-245 Medicare and Medicaid Programs OASIS Collection 
Requirements as Part of the CoPs for HHAs and Supp. Regs. in 42 CFR 
48.55, 484.205, 484.245, 484.250.
    CMS-1572 Home Health Agency Survey and Deficiencies Report.
    CMS-250-254 Medicare Secondary Payer Information Collection and 
Supporting Regulations.
    CMS-379 Financial Statement of Debtor and Supporting Regulations.
    CMS-4040 Request for Enrollment in Supplementary Medical Insurance.
    CMS-10174 Collection of Prescription Drug Event Data from 
Contracted Part D Providers for Payment.
    CMS-10261 Part C Medicare Advantage Reporting Requirements and 
Supporting Regulations.
    CMS-R-285 Request for Retirement Benefit 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 requires federal agencies to publish a 60-day notice in the 
Federal Register concerning each proposed collection of information, 
including each proposed extension 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.

Information Collections

    1. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Conditions for Payment of Power Mobility Devices, including 
Power Wheelchairs and Power-Operated Vehicles; Use: We are renewing our 
request for approval for the collection requirements associated with 
the final rule, CMS-3017-F (71 FR 17021), which published on April 5, 
2006, and required a face-to-face examination of the beneficiary by the 
physician or treating practitioner, a written prescription, and receipt 
of pertinent parts of the medical record by the supplier within 45 days 
after the face-to-face examination that the durable medical equipment 
(DME) suppliers maintain in their records and make available to CMS and 
its agents upon request. Form Number: CMS-10116 (OCN: 0938-0971); 
Frequency: Yearly; Affected Public: Private Sector--Business or other 
for-profits; Number of Respondents: 90,521; Number of Responses: 
173,810; Total Annual Hours: 34,762. (For policy questions regarding 
this collection contact Susan Miller at 410-786-2118.)
    2. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: OASIS Collection 
Requirements as Part of the CoPs for HHAs and Supporting Regulations; 
Use: The OASIS data set is currently mandated for use by Home Health 
Agencies (HHAs) as a condition of participation (CoP) in the Medicare 
program. Since 1999, the Medicare CoPs have mandated that HHAs use the 
OASIS data set when evaluating adult non-maternity patients receiving 
skilled services. The OASIS is a core standard assessment data set that 
agencies integrate into their own patient-specific, comprehensive 
assessment to identify each patient's need for home care that meets the 
patient's medical, nursing, rehabilitative, social, and discharge 
planning needs. Form Number: CMS-R-245 (OCN: 0938-0760); Frequency: 
Occasionally; Affected Public: Private Sector (Business or other for-
profit and Not-for-profit institutions); Number of Respondents: 12,014; 
Total Annual Responses: 17,268,890; Total Annual Hours: 15,305,484. 
(For policy questions regarding this collection contact Robin Dowell at 
410-786-0060.)
    3. Type of Information Collection Request: Reinstatement with 
change of a previously approved collection; Title of Information 
Collection: Home Health Agency Survey and Deficiencies Report; Use: In 
order to participate in the Medicare Program as a Home Health Agency 
(HHA) provider, the HHA must meet federal standards. This form is used 
to record information and patients' health and provider compliance with 
requirements and to report the information to the federal government. 
Form Number: CMS-1572 (OCN: 0938-0355); Frequency: Yearly; Affected 
Public: State, Local or Tribal Government; Number of Respondents: 
3,830; Total Annual Responses: 3,830; Total Annual Hours: 958. (For 
policy questions regarding this collection contact Patricia Sevast at 
410-786-8135.)
    4. Type of Information Collection Request: Reinstatement without 
change

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of a previously approved collection; Title of Information Collection: 
Medicare Secondary Payer Information Collection and Supporting 
Regulations; Use: We are seeking to renew approval to collect 
information from beneficiaries, providers, physicians, insurers, and 
suppliers on health insurance coverage that is primary to Medicare. 
Collecting this information allows us to identify those Medicare 
beneficiaries who are in situations where Medicare is statutorily 
required to be a secondary payer (MSP), thereby safeguarding the 
Medicare Trust Fund. Specifically, we use the information to accurately 
process and pay Medicare claims and to make necessary recoveries in 
accordance with Sec.  1862(b) of the Act (42 U.S.C. 1395y(b)). If an 
active MSP situation is identified and Medicare is inappropriately 
billed as primary, the claim will be rejected. The hospitals, other 
providers, physicians, pharmacies, and suppliers use the information 
collected (and furnished to them on the denial) to properly bill the 
appropriate primary payer. Completing an MSP questionnaire and making 
an accurate MSP determination helps hospitals, other providers, 
physicians, pharmacies, and suppliers to bill correctly the first time, 
saving the Medicare Program money and affording Medicare beneficiaries 
an enhanced level of customer service (which, again, is particularly 
important in Part D due to the real-time adjudication of claims and the 
complicated nature of its benefit administration). Insurers, 
underwriters, third party administrators, and self-insured/self-
administered employers use the information to ensure compliance with 
the law by refunding any identified mistaken payments to Medicare. Form 
Number: CMS-250-254 (OCN: 0938-0214); Frequency: Occasionally; Affected 
Public: Individuals and Households, Private Sector, State, Local or 
Tribal Governments; Number of Respondents: 143,070,217; Total Annual 
Responses: 143,070,217; Total Annual Hours: 1,788,057. (For policy 
questions regarding this collection contact Ward Marsh at 410-786-
6473.)
    5. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Financial Statement of Debtor and Supporting Regulations; 
Use: The form CMS-379 is used to collect financial information which is 
needed to evaluate requests from physicians and suppliers to pay 
indebtedness under an extended repayment schedule, or to compromise a 
debt less than the full amount. Normally, when a Medicare 
Administrative Contractor (MAC) overpays a physician or supplier, the 
overpayment is associated with a single claim, and the amount of the 
overpayment is moderate. In these cases, the physician/supplier usually 
refunds the overpaid amount in a lump sum. Alternatively, the MAC may 
recoup the overpaid amount against future payments. A recoupment is the 
recovery by Medicare of any outstanding Medicare debt by reducing 
present or future Medicare payments and applying the amount withheld to 
the indebtedness. The recoupment can be made only if the physician or 
supplier accepts assignment since the MAC makes payment to the 
physician or supplier only on assigned claims.
    Sometimes, however, an overpayment to a physician or supplier is 
exceptionally large, and it cannot be recovered in the normal fashion. 
The large overpayment usually results from aberrant billing practices, 
such as billing for more expensive services than were rendered. This 
could be discovered during routine review of a statistically valid 
sample of claims. The physician or supplier may be unable to refund a 
large overpaid amount in a single payment. The MAC cannot recover the 
overpayment by recoupment if the physician/supplier does not accept 
assignment of future claims, or is not expected to file future claims 
because of going out of business, illness or death. In these unusual 
circumstances, the MAC has authority to approve or deny extended 
repayment schedules up to 12 months, or may recommend to that we 
approve up to 60 months. Before the MAC takes these actions, the MAC 
will require full documentation of the physician's or supplier's 
financial situation. Thus, the physician or supplier must complete form 
CMS-379. Form Number: CMS-379 (OCN: 0938-0270); Frequency: 
Occasionally; Affected Public: Private Sector--Business or other for-
profits; Number of Respondents: 500; Total Annual Responses: 500; Total 
Annual Hours: 1,000. (For policy questions regarding this collection 
contact Ronke Fabayo at 410-786-4460.)
    6. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Request for Enrollment in Supplementary Medical Insurance; 
Use: Form CMS-4040 (and CMS-4040SP) is used to establish entitlement to 
and enrollment in Medicare Part B for beneficiaries who file for Part B 
only. The collected information is used to determine entitlement for 
individuals who meet the requirements in section 1836(2) of the Social 
Security Act as well as the entitlement of the applicant or their 
spouses to an annuity paid by OPM for premium deduction purposes. Form 
Number: CMS-4040 (OCN: 0938-0245); Frequency: Once; Affected Public: 
Individuals or households; Number of Respondents: 10,000; Total Annual 
Responses: 10,000; Total Annual Hours: 2,500. (For policy questions 
regarding this collection contact Lindsay Smith at 410-786-6843.)
    7. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Collection of Prescription Drug Event Data from Contracted 
Part D Providers for Payment; Use: The information users would include 
Pharmacy Benefit Managers, third party administrators and pharmacies 
and prescription drug plans, Medicare Advantage plans that offer 
integrated prescription drug and health care coverage, Fallbacks and 
other plans that offer coverage of outpatient prescription drugs under 
the Medicare Part D benefit to Medicare beneficiaries. The data 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 (OCN: 0938-0982); 
Frequency: Monthly; Affected Public: Private sector (business or other 
for-profits and not-for-profit institutions); Number of Respondents: 
747; Total Annual Responses: 947,881,770; Total Annual Hours: 1,896. 
(For policy questions regarding this collection contact Ivan Iveljic at 
410-786-3312.)
    8. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Part C Medicare 
Advantage Reporting Requirements and Supporting Regulations; Use: There 
are a number of information users of Part C reporting, including CMS 
central and regional office staff that use this information to monitor 
health plans and to hold them accountable for their performance, 
researchers, and other government agencies such as GAO. Health plans 
can use this information to measure and benchmark their performance. We 
intend to make some of these data available for public reporting as 
``display measures'' in 2013. Form Number: CMS-10261 (OCN: 0938-1054); 
Frequency: Yearly and semi-annually; Affected Public: Private sector 
(business or other for-profits); Number of Respondents: 588; Total 
Annual Responses: 6,715; Total Annual Hours: 200,918. (For policy 
questions

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regarding this collection contact Terry Lied at 410-786-8973.)
    9. 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. Form CMS-R-285 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 (OCN: 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 Lindsay Smith at 410-786-6843.)

    Dated: June 18, 2013.
Martique Jones,
Deputy Director, Regulations Development Group, Office of Strategic 
Operations and Regulatory Affairs.
[FR Doc. 2013-14878 Filed 6-20-13; 8:45 am]
BILLING CODE 4120-01-P