[Federal Register Volume 86, Number 69 (Tuesday, April 13, 2021)]
[Notices]
[Pages 19267-19269]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-07478]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-718-721, CMS-724, CMS-2088-17 and CMS-1763]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

AGENCY: Centers for Medicare & Medicaid Services, Health and Human 
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 May 13, 2021.

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ADDRESSES: Written comments and recommendations for the proposed 
information collection should be sent within 30 days of publication of 
this notice to www.reginfo.gov/public/do/PRAMain. Find this particular 
information collection by selecting ``Currently under 30-day Review--
Open for Public Comments'' or by using the search function.
    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' website address at website address at: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.

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 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: Revision of a currently 
approved collection; Title of Information Collection: Business Proposal 
Forms for Quality Improvement Organizations (QIOs); Use: The submission 
of proposal information by current quality improvement associations 
(QIOs) and other bidders, on the appropriate forms, will satisfy our 
need for meaningful, consistent, and verifiable data with which to 
evaluate contract proposals. We use the data collected on the forms 
associated with this information collection request to negotiate QIO 
contracts. We will be able to compare the costs reported by the QIOs on 
the cost reports to the proposed costs noted on the business proposal 
forms. Subsequent contract and modification negotiations will be based 
on historic cost data. The business proposal forms will be one element 
of the historical cost data from which we can analyze future proposed 
costs. In addition, the business proposal format will standardize the 
cost proposing and pricing process among all QIOs. With well-defined 
cost centers and line items, proposals can be compared among QIOs for 
reasonableness and appropriateness. Form Number: CMS-718-721 (OMB 
control number: 0938-0579); Frequency: Annually; Affected Public: 
Business or other for-profits and Not-for-profit institutions; Number 
of Respondents: 58; Total Annual Responses: 58; Total Annual Hours: 
2,320. (For policy questions regarding this collection contact Benjamin 
Bernstein at 410-786-6570.)
    2. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Medicare/Medicaid Psychiatric Hospital Survey Data and 
Supporting Regulations; Use: The CMS-724 form is used to collect data 
that assists us in program planning and evaluation and in maintaining 
an accurate database on providers participating in the psychiatric 
hospital program. Specifically, we use the information collected on 
this form in evaluating the Medicare psychiatric hospital program. The 
form is also used for audit purposes; determining patient population 
and characteristics of the hospital; and survey term composition. Form 
Number: CMS-724 (OMB control number: 0938-0378); Frequency: Annually; 
Affected Public: Business or other for-profits and Not-for-profit 
institutions; Number of Respondents: 19; Total Annual Responses: 191; 
Total Annual Hours: 96. (For policy questions regarding this collection 
contact Caroline Gallaher at 410-786-8705.)
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Community Mental 
Health Center Cost Report Use: CMS requires the Form CMS-2088-17 to 
determine a provider's reasonable cost incurred in furnishing medical 
services to Medicare beneficiaries and reimbursement due to or from a 
provider. In addition, CMHCs may receive reimbursement through the cost 
report for Medicare reimbursable bad debts. CMS uses the Form CMS-2088-
17 for rate setting; payment refinement activities, including market 
basket analysis; Medicare Trust Fund projections; and to support 
program operations. The primary function of the cost report is to 
determine provider reimbursement for services rendered to Medicare 
beneficiaries. Each CMHC submits the cost report to its contractor for 
reimbursement determination.
    Section 1874A of the Act describes the functions of the contractor. 
CMHCs must follow the principles of cost reimbursement, which require 
they maintain sufficient financial records and statistical data for 
proper determination of costs. The S series of worksheets collects the 
provider's location, CBSA, date of certification, operations, and 
unduplicated census days. The A series of worksheets collects the 
provider's trial balance of expenses for overhead costs, direct patient 
care services, and non-revenue generating cost centers. The B series of 
worksheets allocates the overhead costs to the direct patient care and 
non-revenue generating cost centers using functional statistical bases. 
The Worksheet C computes the apportionment of costs between Medicare 
beneficiaries and other patients. The D series of worksheets are 
Medicare specific and calculate the reimbursement settlement for 
services rendered to Medicare beneficiaries. The Worksheet F collects 
the provider's revenues and expenses data from the provider's income 
statement. Form Number: CMS-2088-17 (OMB control number: 0938-0378); 
Frequency: Annually; Affected Public: Private Sector, Business or other 
for-profits, Not-for-profits institutions; Number of Respondents: 184; 
Total Annual Responses: 184; Total Annual Hours: 16,560. (For policy 
questions regarding this collection contact Jill Keplinger at 410-786-
4550.)
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Termination of Premium-Hospital and or Supplementary Medical Insurance; 
Use: Form CMS-1763 provides the necessary information to process the 
enrollee's request for termination of Part B and/or premium Part A 
coverage.
    Sections 1818(c)(5), 1818A(c)(2)(B) and 1838(b)(1) of the Act and 
corresponding regulations at 42 CFR 406.28(a) and 407.27(c) require 
that a Medicare enrollee wishing to voluntarily terminate Part B and/or 
premium Part A coverage file a written request with CMS or SSA. The 
statute and regulations also specify when coverage ends based upon the 
date the request for termination is filed.
    Form CMS-1763 collects the information necessary to process 
Medicare enrollment terminations. The Request for Termination of 
Premium

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Hospital and/or Supplementary Medical Insurance (Form CMS-1763) 
provides a standardized means to satisfy the requirements of law, as 
well as allow both agencies to protect the individual from an 
inappropriate decision. Form Number: CMS-1763 (OMB control number: 
0938-0025); Frequency: Annually; Affected Public: State, Local, or 
Tribal Governments; Number of Respondents: 114,215; Total Annual 
Responses: 114,215; Total Annual Hours: 19,074. (For policy questions 
regarding this collection contact Carla Patterson at 410-786-1000.)

    Dated: April 7, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2021-07478 Filed 4-12-21; 8:45 am]
BILLING CODE 4120-01-P