[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