Agency Information Collection Activities: Proposed Collection; Comment Request, 91175-91177 [2016-30340]
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Federal Register / Vol. 81, No. 242 / Friday, December 16, 2016 / Notices
mstockstill on DSK3G9T082PROD with NOTICES
aligned to an ACO) targets—both for
Medicare and across all significant
healthcare payers. Additionally, CMS
and Vermont aim for this Model to
deliver meaningful improvements in the
health of a state’s entire population by
transforming the relationships between
and amongst care delivery and public
health systems across Vermont.
II. Provisions of the Notice
The purpose of this notice is to
announce a single source cooperative
agreement funding opportunity in the
amount of $9,500,000 available solely to
Vermont’s Agency of Human Services
(AHS) to support care coordination and
bolster collaboration for practices and
community-based health care providers
as part of the Vermont All-Payer ACO
Model. A single-source award to the
AHS will enable CMS to provide
assistance to Vermont for the following
purposes: To connect Medicare fee-forservice beneficiaries with communitybased resources, coordinate transitions
across care settings with appropriate
involvement of the Medicare fee-forservice beneficiaries’ primary care
providers, coordinate care across health
care providers, support health
promotion and self-management by
Medicare fee-for-service beneficiaries,
and support practice improvement and
transformation. These activities are
necessary for Vermont to achieve the
health outcomes and financial goals
required under the Vermont All-Payer
ACO Model.
CMS and Vermont believe the
Vermont All-Payer ACO Model can
support health care providers, including
physicians in small practices, to
succeed as health care moves from feefor-service to value-based payment
systems. Participation by health care
providers and payers in the model will
be voluntary, and CMS and Vermont
expect to work closely together to
achieve sufficient uptake. In particular,
this Model is being implemented using
the Secretary’s authority in section
1115A of the Social Security Act (the
Act) and Vermont’s Global Commitment
to Health demonstration project
authorized under section 1115 of the
Act. Together these authorities make it
possible for physicians and other
clinicians in Vermont to participate the
aligned and state-specific Vermont
Medicare ACO Initiative and Medicaid
ACO initiative. Under the Quality
Payment Program, the two-sided risk
portion of the Vermont Medicare ACO
Initiative meets the criteria to be an
Advanced Alternative Payment Model.
Health care providers participating in
the two-sided risk portion of the
Vermont Medicare ACO Initiative may
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potentially qualify for the APM
Incentive Payments starting in
performance year 2018.
This single-source funding
opportunity to the AHS is designed to
meet the goals of the cooperative
agreement based on the AHS’ existing
knowledge and role in supporting the
Model, its existing partnerships and
collaborations with Vermont health care
providers, and its resources and ability
to deploy the funding immediately.
III. Collection of Information
Requirements
This document does not impose
information collection requirements,
that is, reporting, recordkeeping or
third-party disclosure requirements.
Consequently, there is no need for
review by the Office of Management and
Budget under the authority of the
Paperwork Reduction Act of 1995 (44
U.S.C. 3501 et seq.).
Dated: December 6, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare
& Medicaid Services.
[FR Doc. 2016–30269 Filed 12–15–16; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifiers: CMS–4040, CMS–
10156, CMS–10170, CMS–10198, CMS–
10227, CMS–10344, CMS–10501, CMS–R–
266, and CMS–10282]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
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
any of the following subjects: the
necessity and utility of the proposed
SUMMARY:
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91175
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
February 14, 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 https://
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 ll 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.hhs.gov/
PaperworkReductionActof1995.
2. Email your request, including your
address, phone number, OMB number,
and CMS document identifier, to
Paperwork@cms.hhs.gov.
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–4040 Request for Enrollment in
Supplementary Medical Insurance
CMS–10156 Retiree Drug Subsidy
(RDS) Application and Instructions
CMS–10170 Retiree Drug Subsidy
(RDS) Payment Request and
Instructions
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Federal Register / Vol. 81, No. 242 / Friday, December 16, 2016 / Notices
CMS–10198 Creditable Coverage
Disclosure to CMS On-Line Form
and Instructions
CMS–10227 PACE State Plan
Amendment Preprint
CMS–10344 Elimination of CostSharing for Full Benefit DualEligible Individuals Receiving
Home and Community-Based
Services
CMS–10501 Healthcare Fraud
Prevention Partnership HFPP Data
Sharing and Information Exchange
CMS–R–266 Medicaid
Disproportionate Share Hospital
Annual Reporting
CMS–10282 Conditions of
Participation for Comprehensive
Outpatient Rehabilitation Facilities
(CORFs) and Supporting
Regulations
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.
mstockstill on DSK3G9T082PROD with NOTICES
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; Use: Form CMS–4040 is used
to establish entitlement to and
enrollment in Medicare Part B for
beneficiaries who file for Part B only.
The collected information is used to
determine entitlement for individuals
who meet the requirements in section
1836(2) of the Social Security Act as
well as the entitlement of the applicant
(or their spouses) to an annuity paid by
OPM for premium deduction purposes.
Form Number: CMS–4040 (OMB control
number: 0938–0245); Frequency: Once;
Affected Public: Individuals or
households; Number of Respondents:
10,000; Total Annual Responses:
10,000; Total Annual Hours: 2,500. (For
policy questions regarding this
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collection contact Carla Patterson at
410–786–8911.)
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Retiree Drug
Subsidy (RDS) Application and
Instructions; Use: Plan sponsors (e.g.,
employers, unions) who offer
prescription drug coverage to their
qualified covered retirees are eligible to
receive a 28 percent tax-free subsidy for
allowable drug costs. To qualify, plan
sponsors must submit a complete
application with a list of retirees for
whom it intends to collect the subsidy.
Once we review and analyze the
information on the application and the
retiree list, notification will be sent to
the plan sponsor about its eligibility to
participate in the RDS program. Form
Number: CMS–10156 (OMB control
number: 0938–0957); Frequency: Yearly
and monthly; Affected Public: Private
sector (Business or other for-profits and
Not-for-profit institutions); Number of
Respondents: 2,482; Total Annual
Responses: 2,482; Total Annual Hours:
158,848. (For policy questions regarding
this collection contact Ivan Iveljic at
410–786–3312.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Retiree Drug
Subsidy (RDS) Payment Request and
Instructions; Use: Plan sponsors (e.g.,
employers, unions) who offer
prescription drug coverage meeting
specified criteria to their qualified
covered retirees are eligible to receive a
28 percent tax-free subsidy for allowable
drug costs. Plan sponsors must submit
required prescription drug cost data and
other information in order to receive the
subsidy. Plan sponsors may elect to
submit RDS payment requests on a
monthly, quarterly, interim annual, or
annual basis; once selected, the
payment frequency may not be changed
during the plan year. Form Number:
CMS–10170 (OMB control number:
0938–0977); Frequency: Occasionally;
Affected Public: Private sector (Business
or other for-profits and Not-for-profit
institutions); Number of Respondents:
2,482; Total Annual Responses: 2,482;
Total Annual Hours: 374,782. (For
policy questions regarding this
collection contact Ivan Iveljic at 410–
786–3312.)
4. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Creditable
Coverage Disclosure to CMS On-Line
Form and Instructions; Use: Most
entities that currently provide
prescription drug benefits to any
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Medicare Part D eligible individual
must disclose whether their prescription
drug benefit is creditable (expected to
pay at least as much, on average, as the
standard prescription drug plan under
Medicare). The disclosure must be
provided annually and upon any change
that affects whether the coverage is
creditable prescription drug coverage.
Form Number: CMS–10198 (OMB
control number: 0938–1013); Frequency:
Yearly and semi-annually; Affected
Public: Private sector (Business or other
for-profits and Not-for-profit
institutions), and State, Local, or Tribal
Governments; Number of Respondents:
85,635; Total Annual Responses:
87,265; Total Annual Hours: 7,272. (For
policy questions regarding this
collection contact Tammie Wall at 410–
786–3317.)
5. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: PACE State Plan
Amendment Preprint; Use: If a state
elects to offer PACE as an optional
Medicaid benefit, it must complete a
state plan amendment preprint packet
described as ‘‘Enclosures 3, 4, 5, 6, and
7.’’ CMS will review the information
provided in order to determine if the
state has properly elected to cover PACE
services as a state plan option. In the
event that the state changes something
in the state plan, only the affected page
must be updated. Form Number: CMS–
10227 (OMB control number: 0938–
1027); Frequency: Once and
occasionally; Affected Public: State,
Local, or Tribal Governments; Number
of Respondents: 7; Total Annual
Responses: 2; Total Annual Hours: 140.
(For policy questions regarding this
collection contact Angela Cimino at
410–786–2638.)
6. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Elimination of
Cost-Sharing for Full Benefit DualEligible Individuals Receiving Home
and Community-Based Services; Use:
This collection eliminates Part D costsharing for full benefit dual-eligible
beneficiaries who are receiving home
and community based services. In this
regard, states are required to identify the
affected beneficiaries in their monthly
Medicare Modernization Act Phase
Down reports. Form Number: CMS–
10344 (OMB control number: 0938–
1127); Frequency: Monthly; Affected
Public: Private sector (Business or other
for-profits and Not-for-profit
institutions); Number of Respondents:
51; Total Annual Responses: 612; Total
Annual Hours: 612. (For policy
questions regarding this collection
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Federal Register / Vol. 81, No. 242 / Friday, December 16, 2016 / Notices
contact Roland Herrera at 410–786–
0668.)
7. Type of Information Collection
Request: Revision of a previously
approved collection; Title of
Information Collection: Healthcare
Fraud Prevention Partnership (HFPP):
Data Sharing and Information Exchange;
Use: The advance directives
requirement was enacted because
Congress wanted individuals to know
that they have a right to make health
care decisions and to refuse treatment
even when they are unable to
communicate. Steps have been taken at
both the Federal and State level, to
afford greater opportunity for the
individual to participate in decisions
made concerning the medical treatment
to be received by an adult patient in the
event that the patient is unable to
communicate to others, a preference
about medical treatment. The individual
may make his preference known
through the use of an advance directive,
which is a written instruction prepared
in advance, such as a living will or
durable power of attorney. This
information is documented in a
prominent part of the individual’s
medical record. Advance directives as
described in the Patient SelfDetermination Act have increased the
individual’s control over decisions
concerning medical treatment. Sections
4206 of the Omnibus Budget
Reconciliation Act of 1990 defined an
advance directive as a written
instruction recognized under State law
relating to the provision of health care
when an individual is incapacitated
(those persons unable to communicate
their wishes regarding medical
treatment).
All states have enacted legislation
defining a patient’s right to make
decisions regarding medical care,
including the right to accept or refuse
medical or surgical treatment and the
right to formulate advance directives.
Participating hospitals, skilled nursing
facilities, nursing facilities, home health
agencies, providers of home health care,
hospices, religious nonmedical health
care institutions, and prepaid or eligible
organizations (including Health Care
Prepayment Plans (HCPPs) and
Medicare Advantage Organizations
(MAOs) such as Coordinated Care Plans,
Demonstration Projects, Chronic Care
Demonstration Projects, Program of All
Inclusive Care for the Elderly, Private
Fee for Service, and Medical Savings
Accounts must provide written
information, at explicit time frames, to
all adult individuals about: (a) The right
to accept or refuse medical or surgical
treatments; (b) the right to formulate an
advance directive; (c) a description of
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18:42 Dec 15, 2016
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applicable State law (provided by the
State); and (d) the provider’s or
organization’s policies and procedures
for implementing an advance directive.
Form Number: CMS–10507 (OMB
control number: 0938–1251); Frequency:
Occasionally; Affected Public: Private
sector (Business or other for-profits);
Number of Respondents: 20; Total
Annual Responses: 20; Total Annual
Hours: 160. (For policy questions
regarding this collection contact Marnie
Dorsey at 410–786–5942.)
8. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Medicaid
Disproportionate Share Hospital (DSH)
Annual Reporting Requirements; Use:
States are required to submit an annual
report that identifies each
disproportionate share hospital (DSH)
that received a DSH payment under the
state’s Medicaid program in the
preceding fiscal year and the amount of
DSH payments paid to that hospital in
the same year along with other
information that the Secretary
determines necessary to ensure the
appropriateness of DSH payments; Form
Number: CMS–R–266 (OMB control
number: 0938–0746); Frequency: Yearly;
Affected Public: State, Local, or Tribal
Governments; Number of Respondents:
51; Total Annual Responses: 51; Total
Annual Hours: 2,142. (For policy
questions regarding this collection
contact Robert Lane at 410–786–2015.)
9. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Conditions of
Participation for Comprehensive
Outpatient Rehabilitation Facilities
(CORFs) and Supporting Regulations;
Use: The Conditions of Participation
(CoPs) and accompanying requirements
specified in the regulations are used by
our surveyors as a basis for determining
whether a comprehensive outpatient
rehabilitation facility (CORF) qualifies
to be awarded a Medicare provider
agreement. We believe the health care
industry practice demonstrates that the
patient clinical records and general
content of records are necessary to
ensure the well-being and safety of
patients and that professional treatment
and accountability are a normal part of
industry practice. Form Number: CMS–
10282 (OMB control number: 0938–
1091); Frequency: Yearly; Affected
Public: Private sector—Business or other
for-profit and Not-for-profit institutions;
Number of Respondents: 549; Total
Annual Responses: 549; Total Annual
Hours: 6,945. (For policy questions
regarding this collection contact
Jacqueline Leach at 410–786–4282.)
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91177
Dated: December 13, 2016.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2016–30340 Filed 12–15–16; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifiers: CMS–2744]
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
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 any of the
following subjects: 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.
SUMMARY:
Comments on the collection(s) of
information must be received by the
OMB desk officer by January 17, 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:
OIRA_ submission@omb.eop.gov.
DATES:
E:\FR\FM\16DEN1.SGM
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Agencies
[Federal Register Volume 81, Number 242 (Friday, December 16, 2016)]
[Notices]
[Pages 91175-91177]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-30340]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-4040, CMS-10156, CMS-10170, CMS-10198, CMS-
10227, CMS-10344, CMS-10501, CMS-R-266, and CMS-10282]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Centers for Medicare & Medicaid Services, HHS.
ACTION: Notice.
-----------------------------------------------------------------------
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 any of the following subjects: 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 February 14, 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
https://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.hhs.gov/PaperworkReductionActof1995.
2. Email your request, including your address, phone number, OMB
number, and CMS document identifier, to Paperwork@cms.hhs.gov.
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-4040 Request for Enrollment in Supplementary Medical Insurance
CMS-10156 Retiree Drug Subsidy (RDS) Application and Instructions
CMS-10170 Retiree Drug Subsidy (RDS) Payment Request and Instructions
[[Page 91176]]
CMS-10198 Creditable Coverage Disclosure to CMS On-Line Form and
Instructions
CMS-10227 PACE State Plan Amendment Preprint
CMS-10344 Elimination of Cost-Sharing for Full Benefit Dual-Eligible
Individuals Receiving Home and Community-Based Services
CMS-10501 Healthcare Fraud Prevention Partnership HFPP Data Sharing and
Information Exchange
CMS-R-266 Medicaid Disproportionate Share Hospital Annual Reporting
CMS-10282 Conditions of Participation for Comprehensive Outpatient
Rehabilitation Facilities (CORFs) and Supporting Regulations
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; Use: Form CMS-4040 is
used to establish entitlement to and enrollment in Medicare Part B for
beneficiaries who file for Part B only. The collected information is
used to determine entitlement for individuals who meet the requirements
in section 1836(2) of the Social Security Act as well as the
entitlement of the applicant (or their spouses) to an annuity paid by
OPM for premium deduction purposes. Form Number: CMS-4040 (OMB control
number: 0938-0245); Frequency: Once; Affected Public: Individuals or
households; Number of Respondents: 10,000; Total Annual Responses:
10,000; Total Annual Hours: 2,500. (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: Retiree Drug
Subsidy (RDS) Application and Instructions; Use: Plan sponsors (e.g.,
employers, unions) who offer prescription drug coverage to their
qualified covered retirees are eligible to receive a 28 percent tax-
free subsidy for allowable drug costs. To qualify, plan sponsors must
submit a complete application with a list of retirees for whom it
intends to collect the subsidy. Once we review and analyze the
information on the application and the retiree list, notification will
be sent to the plan sponsor about its eligibility to participate in the
RDS program. Form Number: CMS-10156 (OMB control number: 0938-0957);
Frequency: Yearly and monthly; Affected Public: Private sector
(Business or other for-profits and Not-for-profit institutions); Number
of Respondents: 2,482; Total Annual Responses: 2,482; Total Annual
Hours: 158,848. (For policy questions regarding this collection contact
Ivan Iveljic at 410-786-3312.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Retiree Drug
Subsidy (RDS) Payment Request and Instructions; Use: Plan sponsors
(e.g., employers, unions) who offer prescription drug coverage meeting
specified criteria to their qualified covered retirees are eligible to
receive a 28 percent tax-free subsidy for allowable drug costs. Plan
sponsors must submit required prescription drug cost data and other
information in order to receive the subsidy. Plan sponsors may elect to
submit RDS payment requests on a monthly, quarterly, interim annual, or
annual basis; once selected, the payment frequency may not be changed
during the plan year. Form Number: CMS-10170 (OMB control number: 0938-
0977); Frequency: Occasionally; Affected Public: Private sector
(Business or other for-profits and Not-for-profit institutions); Number
of Respondents: 2,482; Total Annual Responses: 2,482; Total Annual
Hours: 374,782. (For policy questions regarding this collection contact
Ivan Iveljic at 410-786-3312.)
4. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Creditable
Coverage Disclosure to CMS On-Line Form and Instructions; Use: Most
entities that currently provide prescription drug benefits to any
Medicare Part D eligible individual must disclose whether their
prescription drug benefit is creditable (expected to pay at least as
much, on average, as the standard prescription drug plan under
Medicare). The disclosure must be provided annually and upon any change
that affects whether the coverage is creditable prescription drug
coverage. Form Number: CMS-10198 (OMB control number: 0938-1013);
Frequency: Yearly and semi-annually; Affected Public: Private sector
(Business or other for-profits and Not-for-profit institutions), and
State, Local, or Tribal Governments; Number of Respondents: 85,635;
Total Annual Responses: 87,265; Total Annual Hours: 7,272. (For policy
questions regarding this collection contact Tammie Wall at 410-786-
3317.)
5. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: PACE State Plan
Amendment Preprint; Use: If a state elects to offer PACE as an optional
Medicaid benefit, it must complete a state plan amendment preprint
packet described as ``Enclosures 3, 4, 5, 6, and 7.'' CMS will review
the information provided in order to determine if the state has
properly elected to cover PACE services as a state plan option. In the
event that the state changes something in the state plan, only the
affected page must be updated. Form Number: CMS-10227 (OMB control
number: 0938-1027); Frequency: Once and occasionally; Affected Public:
State, Local, or Tribal Governments; Number of Respondents: 7; Total
Annual Responses: 2; Total Annual Hours: 140. (For policy questions
regarding this collection contact Angela Cimino at 410-786-2638.)
6. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Elimination of
Cost-Sharing for Full Benefit Dual-Eligible Individuals Receiving Home
and Community-Based Services; Use: This collection eliminates Part D
cost-sharing for full benefit dual-eligible beneficiaries who are
receiving home and community based services. In this regard, states are
required to identify the affected beneficiaries in their monthly
Medicare Modernization Act Phase Down reports. Form Number: CMS-10344
(OMB control number: 0938-1127); Frequency: Monthly; Affected Public:
Private sector (Business or other for-profits and Not-for-profit
institutions); Number of Respondents: 51; Total Annual Responses: 612;
Total Annual Hours: 612. (For policy questions regarding this
collection
[[Page 91177]]
contact Roland Herrera at 410-786-0668.)
7. Type of Information Collection Request: Revision of a previously
approved collection; Title of Information Collection: Healthcare Fraud
Prevention Partnership (HFPP): Data Sharing and Information Exchange;
Use: The advance directives requirement was enacted because Congress
wanted individuals to know that they have a right to make health care
decisions and to refuse treatment even when they are unable to
communicate. Steps have been taken at both the Federal and State level,
to afford greater opportunity for the individual to participate in
decisions made concerning the medical treatment to be received by an
adult patient in the event that the patient is unable to communicate to
others, a preference about medical treatment. The individual may make
his preference known through the use of an advance directive, which is
a written instruction prepared in advance, such as a living will or
durable power of attorney. This information is documented in a
prominent part of the individual's medical record. Advance directives
as described in the Patient Self-Determination Act have increased the
individual's control over decisions concerning medical treatment.
Sections 4206 of the Omnibus Budget Reconciliation Act of 1990 defined
an advance directive as a written instruction recognized under State
law relating to the provision of health care when an individual is
incapacitated (those persons unable to communicate their wishes
regarding medical treatment).
All states have enacted legislation defining a patient's right to
make decisions regarding medical care, including the right to accept or
refuse medical or surgical treatment and the right to formulate advance
directives. Participating hospitals, skilled nursing facilities,
nursing facilities, home health agencies, providers of home health
care, hospices, religious nonmedical health care institutions, and
prepaid or eligible organizations (including Health Care Prepayment
Plans (HCPPs) and Medicare Advantage Organizations (MAOs) such as
Coordinated Care Plans, Demonstration Projects, Chronic Care
Demonstration Projects, Program of All Inclusive Care for the Elderly,
Private Fee for Service, and Medical Savings Accounts must provide
written information, at explicit time frames, to all adult individuals
about: (a) The right to accept or refuse medical or surgical
treatments; (b) the right to formulate an advance directive; (c) a
description of applicable State law (provided by the State); and (d)
the provider's or organization's policies and procedures for
implementing an advance directive. Form Number: CMS-10507 (OMB control
number: 0938-1251); Frequency: Occasionally; Affected Public: Private
sector (Business or other for-profits); Number of Respondents: 20;
Total Annual Responses: 20; Total Annual Hours: 160. (For policy
questions regarding this collection contact Marnie Dorsey at 410-786-
5942.)
8. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Medicaid
Disproportionate Share Hospital (DSH) Annual Reporting Requirements;
Use: States are required to submit an annual report that identifies
each disproportionate share hospital (DSH) that received a DSH payment
under the state's Medicaid program in the preceding fiscal year and the
amount of DSH payments paid to that hospital in the same year along
with other information that the Secretary determines necessary to
ensure the appropriateness of DSH payments; Form Number: CMS-R-266 (OMB
control number: 0938-0746); Frequency: Yearly; Affected Public: State,
Local, or Tribal Governments; Number of Respondents: 51; Total Annual
Responses: 51; Total Annual Hours: 2,142. (For policy questions
regarding this collection contact Robert Lane at 410-786-2015.)
9. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Conditions of
Participation for Comprehensive Outpatient Rehabilitation Facilities
(CORFs) and Supporting Regulations; Use: The Conditions of
Participation (CoPs) and accompanying requirements specified in the
regulations are used by our surveyors as a basis for determining
whether a comprehensive outpatient rehabilitation facility (CORF)
qualifies to be awarded a Medicare provider agreement. We believe the
health care industry practice demonstrates that the patient clinical
records and general content of records are necessary to ensure the
well-being and safety of patients and that professional treatment and
accountability are a normal part of industry practice. Form Number:
CMS-10282 (OMB control number: 0938-1091); Frequency: Yearly; Affected
Public: Private sector--Business or other for-profit and Not-for-profit
institutions; Number of Respondents: 549; Total Annual Responses: 549;
Total Annual Hours: 6,945. (For policy questions regarding this
collection contact Jacqueline Leach at 410-786-4282.)
Dated: December 13, 2016.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2016-30340 Filed 12-15-16; 8:45 am]
BILLING CODE 4120-01-P