[Federal Register Volume 81, Number 242 (Friday, December 16, 2016)]
[Notices]
[Pages 91175-91177]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-30340]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifiers: CMS-4040, CMS-10156, CMS-10170, CMS-10198, CMS-
10227, CMS-10344, CMS-10501, CMS-R-266, and CMS-10282]


Agency Information Collection Activities: Proposed Collection; 
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 (the 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 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: 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 must be received by February 14, 2017.

ADDRESSES: When commenting, please reference the document identifier or 
OMB control number. 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:

Contents

    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-4040 Request for Enrollment in Supplementary Medical Insurance
CMS-10156 Retiree Drug Subsidy (RDS) Application and Instructions
CMS-10170 Retiree Drug Subsidy (RDS) Payment Request and Instructions

[[Page 91176]]

CMS-10198 Creditable Coverage Disclosure to CMS On-Line Form and 
Instructions
CMS-10227 PACE State Plan Amendment Preprint
CMS-10344 Elimination of Cost-Sharing for Full Benefit Dual-Eligible 
Individuals Receiving Home and Community-Based Services
CMS-10501 Healthcare Fraud Prevention Partnership HFPP Data Sharing and 
Information Exchange
CMS-R-266 Medicaid Disproportionate Share Hospital Annual Reporting
CMS-10282 Conditions of Participation for Comprehensive Outpatient 
Rehabilitation Facilities (CORFs) and Supporting Regulations

    Under the 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 Collection

    1. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Enrollment in Supplementary Medical Insurance; Use: Form CMS-4040 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 (OMB control 
number: 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 Carla Patterson at 410-786-8911.)
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Retiree Drug 
Subsidy (RDS) Application and Instructions; Use: Plan sponsors (e.g., 
employers, unions) who offer prescription drug coverage to their 
qualified covered retirees are eligible to receive a 28 percent tax-
free subsidy for allowable drug costs. To qualify, plan sponsors must 
submit a complete application with a list of retirees for whom it 
intends to collect the subsidy. Once we review and analyze the 
information on the application and the retiree list, notification will 
be sent to the plan sponsor about its eligibility to participate in the 
RDS program. Form Number: CMS-10156 (OMB control number: 0938-0957); 
Frequency: Yearly and monthly; Affected Public: Private sector 
(Business or other for-profits and Not-for-profit institutions); Number 
of Respondents: 2,482; Total Annual Responses: 2,482; Total Annual 
Hours: 158,848. (For policy questions regarding this collection contact 
Ivan Iveljic at 410-786-3312.)
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Retiree Drug 
Subsidy (RDS) Payment Request and Instructions; Use: Plan sponsors 
(e.g., employers, unions) who offer prescription drug coverage meeting 
specified criteria to their qualified covered retirees are eligible to 
receive a 28 percent tax-free subsidy for allowable drug costs. Plan 
sponsors must submit required prescription drug cost data and other 
information in order to receive the subsidy. Plan sponsors may elect to 
submit RDS payment requests on a monthly, quarterly, interim annual, or 
annual basis; once selected, the payment frequency may not be changed 
during the plan year. Form Number: CMS-10170 (OMB control number: 0938-
0977); Frequency: Occasionally; Affected Public: Private sector 
(Business or other for-profits and Not-for-profit institutions); Number 
of Respondents: 2,482; Total Annual Responses: 2,482; Total Annual 
Hours: 374,782. (For policy questions regarding this collection contact 
Ivan Iveljic at 410-786-3312.)
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Creditable 
Coverage Disclosure to CMS On-Line Form and Instructions; Use: Most 
entities that currently provide prescription drug benefits to any 
Medicare Part D eligible individual must disclose whether their 
prescription drug benefit is creditable (expected to pay at least as 
much, on average, as the standard prescription drug plan under 
Medicare). The disclosure must be provided annually and upon any change 
that affects whether the coverage is creditable prescription drug 
coverage. Form Number: CMS-10198 (OMB control number: 0938-1013); 
Frequency: Yearly and semi-annually; Affected Public: Private sector 
(Business or other for-profits and Not-for-profit institutions), and 
State, Local, or Tribal Governments; Number of Respondents: 85,635; 
Total Annual Responses: 87,265; Total Annual Hours: 7,272. (For policy 
questions regarding this collection contact Tammie Wall at 410-786-
3317.)
    5. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: PACE State Plan 
Amendment Preprint; Use: If a state elects to offer PACE as an optional 
Medicaid benefit, it must complete a state plan amendment preprint 
packet described as ``Enclosures 3, 4, 5, 6, and 7.'' CMS will review 
the information provided in order to determine if the state has 
properly elected to cover PACE services as a state plan option. In the 
event that the state changes something in the state plan, only the 
affected page must be updated. Form Number: CMS-10227 (OMB control 
number: 0938-1027); Frequency: Once and occasionally; Affected Public: 
State, Local, or Tribal Governments; Number of Respondents: 7; Total 
Annual Responses: 2; Total Annual Hours: 140. (For policy questions 
regarding this collection contact Angela Cimino at 410-786-2638.)
    6. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Elimination of 
Cost-Sharing for Full Benefit Dual-Eligible Individuals Receiving Home 
and Community-Based Services; Use: This collection eliminates Part D 
cost-sharing for full benefit dual-eligible beneficiaries who are 
receiving home and community based services. In this regard, states are 
required to identify the affected beneficiaries in their monthly 
Medicare Modernization Act Phase Down reports. Form Number: CMS-10344 
(OMB control number: 0938-1127); Frequency: Monthly; Affected Public: 
Private sector (Business or other for-profits and Not-for-profit 
institutions); Number of Respondents: 51; Total Annual Responses: 612; 
Total Annual Hours: 612. (For policy questions regarding this 
collection

[[Page 91177]]

contact Roland Herrera at 410-786-0668.)
    7. Type of Information Collection Request: Revision of a previously 
approved collection; Title of Information Collection: Healthcare Fraud 
Prevention Partnership (HFPP): Data Sharing and Information Exchange; 
Use: The advance directives requirement was enacted because Congress 
wanted individuals to know that they have a right to make health care 
decisions and to refuse treatment even when they are unable to 
communicate. Steps have been taken at both the Federal and State level, 
to afford greater opportunity for the individual to participate in 
decisions made concerning the medical treatment to be received by an 
adult patient in the event that the patient is unable to communicate to 
others, a preference about medical treatment. The individual may make 
his preference known through the use of an advance directive, which is 
a written instruction prepared in advance, such as a living will or 
durable power of attorney. This information is documented in a 
prominent part of the individual's medical record. Advance directives 
as described in the Patient Self-Determination Act have increased the 
individual's control over decisions concerning medical treatment. 
Sections 4206 of the Omnibus Budget Reconciliation Act of 1990 defined 
an advance directive as a written instruction recognized under State 
law relating to the provision of health care when an individual is 
incapacitated (those persons unable to communicate their wishes 
regarding medical treatment).
    All states have enacted legislation defining a patient's right to 
make decisions regarding medical care, including the right to accept or 
refuse medical or surgical treatment and the right to formulate advance 
directives. Participating hospitals, skilled nursing facilities, 
nursing facilities, home health agencies, providers of home health 
care, hospices, religious nonmedical health care institutions, and 
prepaid or eligible organizations (including Health Care Prepayment 
Plans (HCPPs) and Medicare Advantage Organizations (MAOs) such as 
Coordinated Care Plans, Demonstration Projects, Chronic Care 
Demonstration Projects, Program of All Inclusive Care for the Elderly, 
Private Fee for Service, and Medical Savings Accounts must provide 
written information, at explicit time frames, to all adult individuals 
about: (a) The right to accept or refuse medical or surgical 
treatments; (b) the right to formulate an advance directive; (c) a 
description of applicable State law (provided by the State); and (d) 
the provider's or organization's policies and procedures for 
implementing an advance directive. Form Number: CMS-10507 (OMB control 
number: 0938-1251); Frequency: Occasionally; Affected Public: Private 
sector (Business or other for-profits); Number of Respondents: 20; 
Total Annual Responses: 20; Total Annual Hours: 160. (For policy 
questions regarding this collection contact Marnie Dorsey at 410-786-
5942.)
    8. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicaid 
Disproportionate Share Hospital (DSH) Annual Reporting Requirements; 
Use: States are required to submit an annual report that identifies 
each disproportionate share hospital (DSH) that received a DSH 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 along 
with other information that the Secretary determines necessary to 
ensure the appropriateness of DSH payments; Form Number: CMS-R-266 (OMB 
control number: 0938-0746); Frequency: Yearly; Affected Public: State, 
Local, or Tribal Governments; Number of Respondents: 51; Total Annual 
Responses: 51; Total Annual Hours: 2,142. (For policy questions 
regarding this collection contact Robert Lane at 410-786-2015.)
    9. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Conditions of 
Participation for Comprehensive Outpatient Rehabilitation Facilities 
(CORFs) and Supporting Regulations; Use: The Conditions of 
Participation (CoPs) and accompanying requirements specified in the 
regulations are used by our surveyors as a basis for determining 
whether a comprehensive outpatient rehabilitation facility (CORF) 
qualifies to be awarded a Medicare provider agreement. We believe the 
health care industry practice demonstrates that the patient clinical 
records and general content of records are necessary to ensure the 
well-being and safety of patients and that professional treatment and 
accountability are a normal part of industry practice. Form Number: 
CMS-10282 (OMB control number: 0938-1091); Frequency: Yearly; Affected 
Public: Private sector--Business or other for-profit and Not-for-profit 
institutions; Number of Respondents: 549; Total Annual Responses: 549; 
Total Annual Hours: 6,945. (For policy questions regarding this 
collection contact Jacqueline Leach at 410-786-4282.)

    Dated: December 13, 2016.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2016-30340 Filed 12-15-16; 8:45 am]
 BILLING CODE 4120-01-P