[Federal Register Volume 82, Number 53 (Tuesday, March 21, 2017)]
[Notices]
[Pages 14517-14518]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-05535]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifiers: CMS-40B, CMS-43, CMS-1763, CMS-10174, CMS-10215, 
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 (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 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 May 22, 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 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: 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-40B Application for Enrollment in Medicare the Medical Insurance 
Program
CMS-43 Application for Hospital Insurance Benefits for Individuals 
with End Stage Renal Disease
CMS-1763 Request for Termination of Premium Hospital and 
Supplementary Medical Insurance
CMS-10174 Collection of Prescription Drug Event Data from Contracted 
Part D Providers for Payment
CMS-10215 Medicaid Payment for Prescription Drugs--Physicians and 
Hospital Outpatient Departments Collecting and Submitting Drug 
Identifying Information to State Medicaid Programs
CMS-R-285 Request for Retirement Benefit Information

    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 without change 
of a currently 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: Extension without change 
of a currently 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

[[Page 14518]]

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: Extension without change 
of a currently 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: Revision of a currently 
approved collection; Title of 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: Extension without change 
of a currently 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: Extension without change 
of a currently 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: March 16, 2017.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2017-05535 Filed 3-20-17; 8:45 am]
 BILLING CODE 4120-01-P