Agency Information Collection Activities: Proposed Collection; Comment Request, 73720-73722 [2020-25598]
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Federal Register / Vol. 85, No. 224 / Thursday, November 19, 2020 / Notices
annually, as required by 5 U.S.C.
552a(o) (2)(A)(i), (r), and (u)(3)(D).
5. Publish advance notice of the
matching program in the Federal
Register as required by 5 U.S.C.
552a(e)(12).
This matching program meets these
requirements.
Barbara Demopulos,
Privacy Advisor, Division of Security, Privacy
Policy and Governance, Office of Information
Technology, Centers for Medicare & Medicaid
Services.
PARTICIPATING AGENCIES:
The Department of Health and Human
Services (HHS), Centers for Medicare &
Medicaid Services (CMS) is the
recipient agency, and the Social
Security Administration (SSA) is the
source agency.
AUTHORITY FOR CONDUCTING THE MATCHING
PROGRAM:
The statutory authority for the
matching program is 42 U.S.C. secs.
18081 and 18083.
PURPOSE(S):
The purpose of the matching program
is to provide CMS with SSA information
which CMS and state-based
administering entities will use to
determine individuals’ eligibility for
initial enrollment in a Qualified Health
Plan through an Exchange established
under the Patient Protection and
Affordable Care Act, for Insurance
Affordability Programs (IAPs), and
certificates of exemption from the
shared responsibility payment; and to
make eligibility redeterminations and
renewal decisions, including appeal
determinations. IAPs include:
1. Advance payments of the premium
tax credit (APTC) and cost sharing
reductions (CSRs),
2. Medicaid,
3. Children’s Health Insurance
Program (CHIP), and
4. Basic Health Program (BHP).
CATEGORIES OF INDIVIDUALS:
The individuals whose information
will be used in the matching program
are consumers (applicants and
enrollees) who receive the eligibility
determinations and redeterminations
described in the preceding Purpose(s)
section.
CATEGORIES OF RECORDS:
The categories of records used in the
matching program are identity
information, citizenship, death/
disability indicators, incarceration
information, and income. To request
information from SSA, CMS will submit
a submission file to SSA that contains
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the following mandatory specified data
elements: Last name, first name, date of
birth, Social Security Number (SSN),
and citizenship indicator. When SSA is
able to match the SSN and name
provided by CMS and information is
available, SSA will provide CMS with
the following about each individual, as
relevant: Last name, first name, date of
birth, death indicator, disability
indicator, incarceration information,
Title II (annual and monthly) income
information, and confirmation of
attestations of citizenship status and
SSN. SSA may also provide Quarters of
Coverage data when CMS requests it.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
SYSTEM OF RECORDS MAINTAINED BY CMS
SUMMARY:
CMS Health Insurance Exchanges
System (HIX), CMS System No. 09–70–
0560, last published in full at 78 FR
63211 (Oct. 23, 2013), and amended at
83 FR 6591 (Feb. 14, 2018). Routine use
3 authorizes CMS’ disclosures of
identifying information about applicants
to SSA for use in this matching
program.
B. SYSTEMS OF RECORDS MAINTAINED BY SSA
The SSA SORNs and routine uses that
support this matching program are
identified below:
(1) Master Files of SSN Holders and
SSN Applications, 60–0058, last fully
published at 75 FR 82121 (Dec. 29,
2010) and amended at 78 FR 40542 (July
5, 2013), 79 FR 8780 (Feb. 13, 2014), 83
FR 31250 (July 3, 2018), and 83 FR
54969 (Nov. 1, 2018);
(2) Prisoner Update Processing
System (PUPS), 60–0269, last fully
published at 64 FR 11076 (Mar. 8, 1999)
and amended at 72 FR 69723 (Dec. 10,
2007), 78 FR 40542 (July 5, 2013), and
83 FR 54969 (Nov. 1, 2018);
(3) Master Beneficiary Record, 60–
0090, last fully published at 71 FR 1826
(Jan. 11, 2006), and amended at 72 FR
69723 (Dec. 10, 2007), 78 FR 40542 (July
5, 2013), 83 FR 31250 (July 3, 2018) and
83 FR 54969 (Nov. 1, 2018);
(4) Earnings Recording and SelfEmployment Income System, 60–0059,
last fully published at 71 FR 1819 (Jan.
11, 2006) and amended at 78 FR 40542
(July 5, 2013) and 83 FR 54969 (Nov. 1,
2018).
[FR Doc. 2020–25551 Filed 11–18–20; 8:45 am]
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Centers for Medicare & Medicaid
Services
[Document Identifiers: CMS–10764, CMS–
10454, CMS–R–71, CMS–370/CMS–377,
CMS–1572 and CMS–10332]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, Health and Human
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
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
January 19, 2021.
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,
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Federal Register / Vol. 85, No. 224 / Thursday, November 19, 2020 / Notices
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’ website address at
https://www.cms.gov/Regulations-andGuidance/Legislation/Paperwork
ReductionActof1995/PRA-Listing.html.
2. Call the Reports Clearance Office at
(410) 786–1326.
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–10764 Evaluation of Risk
Adjustment Data Validation (RADV)
Appeals and Health Insurance
Exchange Outreach Training Sessions
CMS–10454 Disclosure of State Rating
Requirements
CMS–R–71 Quality Improvement
Organization (QIO) Assumption of
Responsibilities and Supporting
Regulations
CMS–370/CMS–377 ASC Forms for
Medicare Program Certification
CMS–1572 Home Health Agency
Survey and Deficiencies Report
CMS–10332 Disclosure Requirement
for the In-Office Ancillary Services
Exception
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: New collection (Request for a
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new OMB control number); Title of
Information Collection: Evaluation of
Risk Adjustment Data Validation
(RADV) Appeals and Health Insurance
Exchange Outreach Training Sessions;
Use: CMS recognizes that the success of
accurately identifying risk-adjustment
payments and payment errors is
dependent upon the data submitted by
Medicare Advantage Organizations
(MAOs), and is strongly committed to
providing appropriate education and
technical outreach to MAOs and thirdparty administrators (TPAs). In
addition, CMS is strongly committed to
providing appropriate education and
technical outreach to States, issuers,
self-insured group health plans and
TPAs participating in the Marketplace
and/or market stabilization programs
mandated by the Affordable Care Act
(ACA).
CMS will strengthen outreach and
engagement with MAOs and
stakeholders in the Marketplace through
satisfaction surveys following contractlevel (CON) RADV audit and Health
Insurance Exchange training events. The
survey results will help to determine
stakeholders’ level of satisfaction with
trainings, identify any issues with
training and technical assistance
delivery, clarify stakeholders’ needs and
preferences, and define best practices
for training and technical assistance.
Form Number: CMS–10764 (OMB
control number: 0938–NEW);
Frequency: Occasionally; Affected
Public: Private Sector; Number of
Respondents: 4,270; Total Annual
Responses: 4,270; Total Annual Hours:
1,068. (For questions regarding this
collection contact Melissa Barkai at
410–786–4305.)
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
information Collection: Disclosure of
State Rating Requirements; Use: The
final rule ‘‘Patient Protection and
Affordable Care Act; Health Insurance
Market Rules; Rate Review’’ implements
sections 2701, 2702, and 2703 of the
Public Health Service Act (PHS Act), as
added and amended by the Affordable
Care Act, and sections 1302(e) and
1312(c) of the Affordable Care Act. The
rule directs that states submit to CMS
certain information about state rating
and risk pooling requirements for their
individual, small group, and large group
markets, as applicable. Specifically,
states will inform CMS of age rating
ratios that are narrower than 3:1 for
adults; tobacco use rating ratios that are
narrower than 1.5:1; a state-established
uniform age curve; geographic rating
areas; whether premiums in the small
and large group market are required to
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73721
be based on average enrollee amounts
(also known as composite premiums);
and, in states that do not permit any
rating variation based on age or tobacco
use, uniform family tier structures and
corresponding multipliers. In addition,
states that elect to merge their
individual and small group market risk
pools into a combined pool will notify
CMS of such election. This information
will allow CMS to determine whether
state-specific rules apply or Federal
default rules apply. It will also support
the accuracy of the federal risk
adjustment methodology. Form Number:
CMS–10454 (OMB control number
0938–1258); Frequency: Occasionally;
Affected Public: State, Local, or Tribal
Governments; Number of Respondents:
3; Total Annual Responses: 3; Total
Annual Hours: 17. (For policy questions
regarding this collection contact Russell
Tipps at 301–869–3502.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Quality
Improvement Organization (QIO)
Assumption of Responsibilities and
Supporting Regulations; Use: The Peer
Review Improvement Act of 1982
amended Title XI of the Social Security
Act to create the Utilization and Quality
Control Peer Review Organization (PRO)
program which replaces the Professional
Standards Review Organization (PSRO)
program and streamlines peer review
activities. The term PRO has been
renamed Quality Improvement
Organization (QIO). This information
collection describes the review
functions to be performed by the QIO.
It outlines relationships among QIOs,
providers, practitioners, beneficiaries,
intermediaries, and carriers. Form
Number: CMS–R–71 (OMB control
number: 0938–0445); Frequency: Yearly;
Affected Public: Business or other forprofit and Not-for-profit institutions;
Number of Respondents: 6,939; Total
Annual Responses: 972,478; Total
Annual Hours: 1,034,655. (For policy
questions regarding this collection
contact Kimberly Harris at 401–837–
1118.)
4. Type of Information Collection
Request: Extension of a currently
approved collection; Titles of
Information Collection: ASC Forms for
Medicare Program Certification; Use:
The form CMS–370 titled ‘‘Health
Insurance Benefits Agreement’’ is used
for the purpose of establishing an ASC’s
eligibility for payment under Title XVIII
of the Social Security Act (the ‘‘Act’’).
This agreement, upon acceptance by the
Secretary of Health & Human Services,
shall be binding on the ASC and the
Secretary. The agreement may be
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Federal Register / Vol. 85, No. 224 / Thursday, November 19, 2020 / Notices
terminated by either party in accordance
with regulations. In the event of
termination of this agreement, payment
will not be available for the ASC’s
services furnished to Medicare
beneficiaries on or after the effective
date of termination.
The CMS–377 form is used by ASCs
to initiate both the initial and renewal
survey by the State Survey Agency,
which provides the certification
required for an ASC to participate in the
Medicare program. An ASC must
complete the CMS–377 form and send it
to the appropriate State Survey Agency
prior to their scheduled accreditation
renewal date. The CMS–377 form
provides the State Survey Agency with
information about the ASC facility’s
characteristics, such as, determining the
size and the composition of the survey
team on the basis of the number of ORs/
procedure rooms and the types of
surgical procedures performed in the
ASC. Form Numbers: CMS–370 and
CMS–377 (OMB control number: 0938–
0266); Frequency: Occasionally;
Affected Public: Private Sector—
Business or other for-profit and Not-forprofit institutions; Number of
Respondents: 1,567; Total Annual
Responses: 1,567; Total Annual Hours:
1,012. (For policy questions regarding
this collection contact Caroline Gallaher
at 410–786–8705.)
5. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Home Health
Agency Survey and Deficiencies Report;
Use: In order to participate in the
Medicare Program as a Home Health
Agency (HHA) provider, the HHA must
meet federal standards. This form is
used to record information and patients’
health and provider compliance with
requirements and to report the
information to the federal government.
Form Number: CMS–1572 (OMB control
number: 0938–0355); Frequency: Yearly;
Affected Public: State, Local or Tribal
Government; Number of Respondents:
3,833; Total Annual Responses: 3,833;
Total Annual Hours: 1,917. (For policy
questions regarding this collection
contact Tara Lemons at 410–786–3030.)
6. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Disclosure
Requirement for the In-Office Ancillary
Services Exception; Use: Section 6003 of
the Affordable Care Act (ACA)
established a new disclosure
requirement that a physician must
perform for certain imaging services to
meet the in-office ancillary services
exception to the prohibition of the
physician self-referral law. This section
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of the ACA amended section 1877(b)(2)
of the Act by adding a requirement that
the referring physician informs the
patient, at the time of the referral and in
writing, that the patient may receive the
imaging service from another supplier.
Physicians who provide certain
imaging services (MRI, CT, and PET)
under the in-office ancillary services
exception to the physician self-referral
prohibition are required to provide the
disclosure notice as well as the list of
other imaging suppliers to the patient.
The patient will then be able to use the
disclosure notice and list of suppliers in
making an informed decision about his
or her course of care for the imaging
service.
CMS would use the collected
information for enforcement purposes.
Specifically, if we were investigating the
referrals of a physician providing
advanced imaging services under the inoffice ancillary services exception, we
would review the written disclosure in
order to determine if it satisfied the
requirement. Form Number: CMS–
10332 (OMB control number: 0938–
1133); Frequency: Occasionally;
Affected Public: Private Sector, Business
or other for-profits, Not-for-profits
institutions; Number of Respondents:
2,239; Total Annual Responses:
989,971; Total Annual Hours: 18,694.
(For questions regarding this collection
contact Laura Dash at 410–786–8623.)
Dated: November 16, 2020.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2020–25598 Filed 11–18–20; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Administration for Children and
Families
Proposed Information Collection
Activity; Addition of New Instruments
to Existing Information Collections by
the Office of Refugee Resettlement
(OMB #s: 0970–0553, 0970–0554, and
0970–0547)
Office of Refugee Resettlement,
Administration for Children and
Families, Department of Health and
Human Services.
ACTION: Request for public comment.
AGENCY:
The Office of Refugee
Resettlement (ORR), Administration for
Children and Families (ACF), U.S.
Department of Health and Human
Services (HHS), is inviting public
SUMMARY:
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comments on several proposed
instruments. The instruments will be
added to the following existing
information collections: Services
Provided to Unaccompanied Alien
Children (OMB #0970–0553), Placement
and Transfer of Unaccompanied Alien
Children into ORR Care Provider
Facilities (OMB #0970–0554), and
Administration and Oversight of the
Unaccompanied Alien Children
Program (OMB #0970–0547).
DATES: Comments due within 60 days of
publication. In compliance with the
requirements of Section 3506(c)(2)(A) of
the Paperwork Reduction Act of 1995,
ACF is soliciting public comment on the
specific aspects of the information
collection described in this notice.
ADDRESSES: Copies of the proposed
collection of information can be
obtained and comments may be
forwarded by emailing infocollection@
acf.hhs.gov. Alternatively, copies can
also be obtained by writing to the
Administration for Children and
Families, Office of Planning, Research
and Evaluation (OPRE), 330 C Street
SW, Washington, DC 20201, Attn: ACF
Reports Clearance Officer. All requests,
emailed or written, should be identified
by the title of the information collection.
SUPPLEMENTARY INFORMATION:
Description: The components of these
requests and the existing information
collections to which each component
will be added are as follows:
Services Provided to Unaccompanied
Alien Children Into ORR Care Provider
Facilities (OMB #0970–0553)
1. Admission: This instrument is used
by ORR grantee case managers and
clinicians to document the UAC’s initial
needs, functioning, and history. The
Admission Details tab includes a case
status timeline; biographic information
on the UAC; admission and educational
information; medical clearance
information; influx transfer information,
if applicable; system-generated
information; a clickable, auto-generated
list of Admission Assessments and the
ability to create a new assessment; a
clickable, auto-generated list of Transfer
Requests and the ability to create a new
transfer requests, if applicable; and a
clickable, auto-generated list of Long
Term Foster Care (LTFC) Travel
Requests and the ability to create a new
transfer requests, if applicable. The
Related tab includes areas to upload
case management, education, and
medical documents; an area to add
Entry Team members (individuals
granted read/write access to the
Admission instrument); and an autogenerated list of changes made to the
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]]>Agencies
[Federal Register Volume 85, Number 224 (Thursday, November 19, 2020)]
[Notices]
[Pages 73720-73722]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-25598]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-10764, CMS-10454, CMS-R-71, CMS-370/CMS-377,
CMS-1572 and CMS-10332]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Centers for Medicare & Medicaid Services, Health and Human
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 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 January 19, 2021.
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,
[[Page 73721]]
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' website address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
2. Call the Reports Clearance Office at (410) 786-1326.
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-10764 Evaluation of Risk Adjustment Data Validation (RADV) Appeals
and Health Insurance Exchange Outreach Training Sessions
CMS-10454 Disclosure of State Rating Requirements
CMS-R-71 Quality Improvement Organization (QIO) Assumption of
Responsibilities and Supporting Regulations
CMS-370/CMS-377 ASC Forms for Medicare Program Certification
CMS-1572 Home Health Agency Survey and Deficiencies Report
CMS-10332 Disclosure Requirement for the In-Office Ancillary Services
Exception
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: New collection (Request
for a new OMB control number); Title of Information Collection:
Evaluation of Risk Adjustment Data Validation (RADV) Appeals and Health
Insurance Exchange Outreach Training Sessions; Use: CMS recognizes that
the success of accurately identifying risk-adjustment payments and
payment errors is dependent upon the data submitted by Medicare
Advantage Organizations (MAOs), and is strongly committed to providing
appropriate education and technical outreach to MAOs and third-party
administrators (TPAs). In addition, CMS is strongly committed to
providing appropriate education and technical outreach to States,
issuers, self-insured group health plans and TPAs participating in the
Marketplace and/or market stabilization programs mandated by the
Affordable Care Act (ACA).
CMS will strengthen outreach and engagement with MAOs and
stakeholders in the Marketplace through satisfaction surveys following
contract-level (CON) RADV audit and Health Insurance Exchange training
events. The survey results will help to determine stakeholders' level
of satisfaction with trainings, identify any issues with training and
technical assistance delivery, clarify stakeholders' needs and
preferences, and define best practices for training and technical
assistance. Form Number: CMS-10764 (OMB control number: 0938-NEW);
Frequency: Occasionally; Affected Public: Private Sector; Number of
Respondents: 4,270; Total Annual Responses: 4,270; Total Annual Hours:
1,068. (For questions regarding this collection contact Melissa Barkai
at 410-786-4305.)
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of information Collection: Disclosure of
State Rating Requirements; Use: The final rule ``Patient Protection and
Affordable Care Act; Health Insurance Market Rules; Rate Review''
implements sections 2701, 2702, and 2703 of the Public Health Service
Act (PHS Act), as added and amended by the Affordable Care Act, and
sections 1302(e) and 1312(c) of the Affordable Care Act. The rule
directs that states submit to CMS certain information about state
rating and risk pooling requirements for their individual, small group,
and large group markets, as applicable. Specifically, states will
inform CMS of age rating ratios that are narrower than 3:1 for adults;
tobacco use rating ratios that are narrower than 1.5:1; a state-
established uniform age curve; geographic rating areas; whether
premiums in the small and large group market are required to be based
on average enrollee amounts (also known as composite premiums); and, in
states that do not permit any rating variation based on age or tobacco
use, uniform family tier structures and corresponding multipliers. In
addition, states that elect to merge their individual and small group
market risk pools into a combined pool will notify CMS of such
election. This information will allow CMS to determine whether state-
specific rules apply or Federal default rules apply. It will also
support the accuracy of the federal risk adjustment methodology. Form
Number: CMS-10454 (OMB control number 0938-1258); Frequency:
Occasionally; Affected Public: State, Local, or Tribal Governments;
Number of Respondents: 3; Total Annual Responses: 3; Total Annual
Hours: 17. (For policy questions regarding this collection contact
Russell Tipps at 301-869-3502.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Quality
Improvement Organization (QIO) Assumption of Responsibilities and
Supporting Regulations; Use: The Peer Review Improvement Act of 1982
amended Title XI of the Social Security Act to create the Utilization
and Quality Control Peer Review Organization (PRO) program which
replaces the Professional Standards Review Organization (PSRO) program
and streamlines peer review activities. The term PRO has been renamed
Quality Improvement Organization (QIO). This information collection
describes the review functions to be performed by the QIO. It outlines
relationships among QIOs, providers, practitioners, beneficiaries,
intermediaries, and carriers. Form Number: CMS-R-71 (OMB control
number: 0938-0445); Frequency: Yearly; Affected Public: Business or
other for-profit and Not-for-profit institutions; Number of
Respondents: 6,939; Total Annual Responses: 972,478; Total Annual
Hours: 1,034,655. (For policy questions regarding this collection
contact Kimberly Harris at 401-837-1118.)
4. Type of Information Collection Request: Extension of a currently
approved collection; Titles of Information Collection: ASC Forms for
Medicare Program Certification; Use: The form CMS-370 titled ``Health
Insurance Benefits Agreement'' is used for the purpose of establishing
an ASC's eligibility for payment under Title XVIII of the Social
Security Act (the ``Act''). This agreement, upon acceptance by the
Secretary of Health & Human Services, shall be binding on the ASC and
the Secretary. The agreement may be
[[Page 73722]]
terminated by either party in accordance with regulations. In the event
of termination of this agreement, payment will not be available for the
ASC's services furnished to Medicare beneficiaries on or after the
effective date of termination.
The CMS-377 form is used by ASCs to initiate both the initial and
renewal survey by the State Survey Agency, which provides the
certification required for an ASC to participate in the Medicare
program. An ASC must complete the CMS-377 form and send it to the
appropriate State Survey Agency prior to their scheduled accreditation
renewal date. The CMS-377 form provides the State Survey Agency with
information about the ASC facility's characteristics, such as,
determining the size and the composition of the survey team on the
basis of the number of ORs/procedure rooms and the types of surgical
procedures performed in the ASC. Form Numbers: CMS-370 and CMS-377 (OMB
control number: 0938-0266); Frequency: Occasionally; Affected Public:
Private Sector--Business or other for-profit and Not-for-profit
institutions; Number of Respondents: 1,567; Total Annual Responses:
1,567; Total Annual Hours: 1,012. (For policy questions regarding this
collection contact Caroline Gallaher at 410-786-8705.)
5. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Home Health
Agency Survey and Deficiencies Report; Use: In order to participate in
the Medicare Program as a Home Health Agency (HHA) provider, the HHA
must meet federal standards. This form is used to record information
and patients' health and provider compliance with requirements and to
report the information to the federal government. Form Number: CMS-1572
(OMB control number: 0938-0355); Frequency: Yearly; Affected Public:
State, Local or Tribal Government; Number of Respondents: 3,833; Total
Annual Responses: 3,833; Total Annual Hours: 1,917. (For policy
questions regarding this collection contact Tara Lemons at 410-786-
3030.)
6. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Disclosure
Requirement for the In-Office Ancillary Services Exception; Use:
Section 6003 of the Affordable Care Act (ACA) established a new
disclosure requirement that a physician must perform for certain
imaging services to meet the in-office ancillary services exception to
the prohibition of the physician self-referral law. This section of the
ACA amended section 1877(b)(2) of the Act by adding a requirement that
the referring physician informs the patient, at the time of the
referral and in writing, that the patient may receive the imaging
service from another supplier.
Physicians who provide certain imaging services (MRI, CT, and PET)
under the in-office ancillary services exception to the physician self-
referral prohibition are required to provide the disclosure notice as
well as the list of other imaging suppliers to the patient. The patient
will then be able to use the disclosure notice and list of suppliers in
making an informed decision about his or her course of care for the
imaging service.
CMS would use the collected information for enforcement purposes.
Specifically, if we were investigating the referrals of a physician
providing advanced imaging services under the in- office ancillary
services exception, we would review the written disclosure in order to
determine if it satisfied the requirement. Form Number: CMS-10332 (OMB
control number: 0938-1133); Frequency: Occasionally; Affected Public:
Private Sector, Business or other for-profits, Not-for-profits
institutions; Number of Respondents: 2,239; Total Annual Responses:
989,971; Total Annual Hours: 18,694. (For questions regarding this
collection contact Laura Dash at 410-786-8623.)
Dated: November 16, 2020.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2020-25598 Filed 11-18-20; 8:45 am]
BILLING CODE 4120-01-P
