Agency Information Collection Activities: Submission for OMB Review; Comment Request, 31609-31610 [2017-14230]
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Federal Register / Vol. 82, No. 129 / Friday, July 7, 2017 / Notices
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
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 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 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:
OIRA_submission@omb.eop.gov.
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-
asabaliauskas on DSKBBXCHB2PROD with NOTICES
DATES:
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20:56 Jul 06, 2017
Jkt 241001
Guidance/Legislation/Paperwork
ReductionActof1995/PRA-Listing.html.
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:
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.)
PO 00000
Frm 00062
Fmt 4703
Sfmt 4703
31609
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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Federal Register / Vol. 82, No. 129 / Friday, July 7, 2017 / Notices
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 Notfor-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
VerDate Sep<11>2014
20:56 Jul 06, 2017
Jkt 241001
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
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Health Resources and Services
Administration
Notice of Single Source Award to the
Genesee County Health Department for
Addressing and Preventing Lead
Exposure Through Healthy Start in
Genesee County, Michigan
Health Resources and Services
Administration, HHS.
ACTION: Notice of single source award.
AGENCY:
HRSA announces its intent to
award up to $14,975,000 for a
cooperative agreement to the Genesee
County Health Department, which
operates the Genesee County Healthy
Start program. The purpose of this
cooperative agreement is to expedite
and strengthen the ongoing response to
address the health effects of lead
exposure resulting from the Flint, MI,
public water supply contamination.
SUPPLEMENTARY INFORMATION:
Intended Recipient of the Award:
Genesee County Health Department.
Amount of Non-Competitive Awards:
Up to $14,975,000.
Period of Funding: July 1, 2017–June
30, 2022.
CFDA Number: 93.926.
Authority: Water Infrastructure
Improvements for the Nation (WIIN) Act
(Pub. L. 114–322); Section 330H of the
Public Health Service Act (42 U.S.C.
254c–8), as amended by Public Law
110–339, Section 2; and Further
Continuing and Security Assistance
SUMMARY:
PO 00000
Frm 00063
Fmt 4703
Sfmt 4703
Appropriations Act, 2017 (Pub. L. 114–
254).
Justification: Flint, MI, and the
surrounding community continues to
experience ongoing health needs,
particularly among pregnant women
and young children, associated with
elevated levels of lead in the public
water supply resulting from the city’s
switch from the Detroit Water Authority
to the Flint Water Systems between
April 2013 and October 2015.
On January 5, 2016, the state of
Michigan declared a state of emergency
for Genesee County, which includes the
city of Flint, authorizing the use of state
resources to address the public health
crisis created by the elevated levels of
lead in the public water system. On
January 16, 2016, a federal emergency
was declared for the state of Michigan
and authorized federal assistance to
provide water, water filters, water filter
cartridges, water test kits, and other
necessary related items.
Prenatal lead exposure can affect
fertility, the likelihood of miscarriage,
pre-term birth, low birth weight, infant
neurodevelopment, and gestational
hypertension. Of particular concern are
the long-term effects in children such as
developmental and cognitive delays,
and behavioral disorders. The Healthy
Start program aims to reduce disparities
in infant mortality and improve
perinatal and child health outcomes. To
advance this mission, the goal of this
program is to minimize developmental
delays among lead-exposed children up
to age 6 in Flint and the surrounding
Genesee County area by connecting
them to appropriate screening, services,
and supports.
Thus, HRSA intends to award a onetime, single source cooperative
agreement to the Genesee County Health
Department to expedite and strengthen
the ongoing response to address the
health effects of lead exposure resulting
from the Flint, MI, public water supply
contamination. This award will enable
the Genesee County Health Department
to continue to play a vital role in
assuring all pregnant women and
children impacted by lead
contamination in Genesee County have
access to comprehensive health and
social services. With these funds, the
Genesee County Health Department will
leverage its existing Healthy Start
infrastructure and in-depth
understanding of the maternal and child
population in Genesee County to assess,
mitigate, and provide consultation to
pregnant women and children up to age
6 that may be impacted by lead
exposure during the Flint water crisis.
Activities under this award include
identifying children in Flint and the
E:\FR\FM\07JYN1.SGM
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Agencies
[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]
[[Page 31609]]
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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.
-----------------------------------------------------------------------
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:
OIRA_submission@omb.eop.gov.
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 Paperwork@cms.hhs.gov.
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
[[Page 31610]]
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