[Federal Register Volume 82, Number 129 (Friday, July 7, 2017)]
[Notices]
[Pages 31609-31610]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-14230]



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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, 
and CMS-R-285]


Agency Information Collection Activities: Submission for OMB 
Review; 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 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

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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