[Federal Register Volume 88, Number 43 (Monday, March 6, 2023)]
[Notices]
[Pages 13830-13831]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-04551]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-4040 & CMS-R-297]


Agency Information Collection Activities: Proposed Collection; 
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

[[Page 13831]]

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 5, 2023.

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, please access 
the CMS PRA website by copying and pasting the following web address 
into your web browser: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing

FOR FURTHER INFORMATION CONTACT: William N. Parham at (410) 786-4669.

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 
(SMI)
CMS-R-297 Request for Employment 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 of a currently 
approved collection; Title of Information Collection: Request for 
Enrollment in Supplementary Medical Insurance (SMI); Use: CMS 
regulations 42 CFR 407.11 lists the CMS-4040 as the application to be 
used by individuals who are not eligible for monthly Social Security/
Railroad Retirement Board benefits or free Part A. The CMS-4040 
solicits the information that is used to determine entitlement for 
individuals who meet the requirements in section 1836 as well as the 
entitlement of the applicant or their spouses to an annuity paid by OPM 
for premium deduction purposes. The application follows the application 
questions and requirements used by SSA. This is done not only for 
consistency purposes but to comply with other Title II and Title XVIII 
requirements because eligibility to Title II benefits and free Part A 
under Title XVIII must be ruled out in order to qualify for enrollment 
in Part B only. Form Number: CMS-4040 (OMB control number: 0938-0245); 
Frequency: Once; Affected Public: Individuals or households; Number of 
Respondents: 42,011; Total Annual Responses: 42,011; Total Annual 
Hours: 10,503. (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: Request for 
Employment Information; Use: The form CMS-L564, also referred to as 
CMS-R-297, is used, in conjunction with form CMS-40-B, Application for 
Supplementary Medical Insurance, during an individual's special 
enrollment period (SEP). Completed by an employer, the CMS-L564 
provides proof of an applicant's employer group health coverage. The 
Social Security Administration (SSA) uses it to obtain information from 
employers regarding whether a Medicare beneficiary's coverage under a 
group health plan is based on current employment status. The form is 
available online via Medicare.gov and CMS.gov for individuals who are 
requesting the SEP to obtain and submit to their employer for 
completion. The employer must complete and sign the form, and submit it 
to the individual to accompany their enrollment or late enrollment 
penalty reduction request. The information on the completed form is 
reviewed manually by SSA. Form Number: CMS-R-297 (OMB control number: 
0938-0787); Frequency: Once; Affected Public: Individuals or 
households, Business or other for-profits, Not-for-profit institutions; 
Number of Respondents: 676,526; Total Annual Responses: 676,526; Total 
Annual Hours: 56,355. (For policy questions regarding this collection 
contact Carla Patterson at 410-786-8911.)

    Dated: March 1, 2023.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2023-04551 Filed 3-3-23; 8:45 am]
BILLING CODE 4120-01-P