Agency Information Collection Activities: Proposed Collection; Comment Request, 8362-8364 [2021-02441]
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8362
Federal Register / Vol. 86, No. 23 / Friday, February 5, 2021 / Notices
jbell on DSKJLSW7X2PROD with NOTICES
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 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: Revision of a currently
approved collection; Title of
Information Collection: Medicare
Advantage, Medicare Part D, and
Medicare Fee-For-Service Consumer
Assessment of Healthcare Providers and
Systems (CAHPS) Survey; Use: The
Centers for Medicare & Medicaid
Services (CMS) has authority to collect
various types of quality data under
section 1852(e) of the Act and use this
information to develop and publicly
post a 5-star rating system for Medicare
Advantage (MA) plans based on its
authority to disseminate comparative
information, including about quality, to
beneficiaries under sections 1851(d) and
1860D–1(c) of the Act. As codified at
§ 422.152(b)(3), Medicare health plans
are required to report on quality
performance data which CMS can use to
help beneficiaries compare plans. Cost
plans under section 1876 of the Act are
also included in the MA Star Rating
system, as codified at § 417.472(k), and
are required by regulation (§ 417.472(j))
to make CAHPS survey data available to
CMS.
The MMA under Sec. 1860D–4
(Information to Facilitate Enrollment)
requires CMS to conduct consumer
satisfaction surveys of enrollees in MA
and Part D contracts and report the
results to Medicare beneficiaries prior to
the annual enrollment period. This
request for approval is for CMS to
continue conducting the Medicare
CAHPS surveys annually to meet the
requirement to conduct consumer
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satisfaction surveys regarding the
experiences of beneficiaries with their
health and prescription drug plans.
The primary purpose of the Medicare
CAHPS surveys is to provide
information to Medicare beneficiaries to
help them make more informed choices
among health and prescription drug
plans available to them. Survey results
are reported by CMS in the Medicare &
You handbook published each fall and
on the Medicare Plan Finder website.
Beneficiaries can compare CAHPS
scores for each health and drug plan as
well as compare MA and FFS scores
when making enrollment decisions. The
Medicare CAHPS also provides data to
help CMS and others monitor the
quality and performance of Medicare
health and prescription drug plans and
identify areas to improve the quality of
care and services provided to enrollees
of these plans. CAHPS data are included
in the Medicare Part C & D Star Ratings
and used to calculate MA Quality Bonus
Payments. Form Number: CMS–R–246
(OMB control number: 0938–1088);
Frequency: Annually; Affected Public:
Private Sector; Business or other forprofit and not-for-profit institutions;
Number of Respondents: 537; Total
Annual Responses: 745,350; Total
Annual Hours: 179,108. (For policy
questions regarding this collection
contact Sarah Gaillot at 410–786–4637.)
Dated: February 2, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2021–02439 Filed 2–4–21; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifiers CMS–10203, CMS–
2088–17, CMS–1763, and CMS–1696]
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
SUMMARY:
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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
April 6, 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,
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
website address at https://www.cms.gov/
Regulations-and-Guidance/Legislation/
PaperworkReductionActof1995/PRAListing.html.
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–10203 Medicare Health
Outcomes Survey
E:\FR\FM\05FEN1.SGM
05FEN1
Federal Register / Vol. 86, No. 23 / Friday, February 5, 2021 / Notices
CMS–2088–17 Community Mental
Health Center Cost Report
CMS–1763 Request For Termination of
Premium-Hospital and or
Supplementary Medical Insurance
CMS–1696 Appointment of
Representative
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.
jbell on DSKJLSW7X2PROD with NOTICES
Information Collection
1. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Medicare Health
Outcomes Survey (HOS); Use: The HOS
is a longitudinal patient-reported
outcome measure (PROM) that assesses
self-reported beneficiary quality of life
and daily functioning. As a PROM, the
HOS measures the impact of services
provided by MAOs, whereas process
and patient experience measures only
provide a snapshot of activities or
experiences at a specific point in time.
PROM data collected by the HOS allows
CMS to continue to assess the health of
the Medicare Advantage population.
This older population is at increased
risk of adverse health outcomes,
including chronic diseases and mobility
impairments that may significantly
hamper quality of life. The HOS
supports CMS’s commitment to improve
health outcomes for beneficiaries while
reducing burden on providers. CMS
accomplishes this by focusing on highpriority areas for quality measurement
and improvement established in the
agency’s Meaningful Measures
Framework. The HOS uses quality
measures that ask beneficiaries about
health outcomes related to specific
mental and Physical Conditions. Form
Number: CMS–10203 (OMB control
number: 0938–0701); Frequency:
Annually; Affected Public: Individuals
and Households; Number of
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Respondents: 1,485; Total Annual
Responses: 629,280; Total Annual
Hours: 201,370. (For policy questions
regarding this collection contact Debra
Start at 410–786–6646.)
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Community
Mental Health Center Cost Report Use:
CMS requires the Form CMS–2088–17
to determine a provider’s reasonable
cost incurred in furnishing medical
services to Medicare beneficiaries and
reimbursement due to or from a
provider. In addition, CMHCs may
receive reimbursement through the cost
report for Medicare reimbursable bad
debts. CMS uses the Form CMS–2088–
17 for rate setting; payment refinement
activities, including market basket
analysis; Medicare Trust Fund
projections; and to support program
operations. The primary function of the
cost report is to determine provider
reimbursement for services rendered to
Medicare beneficiaries. Each CMHC
submits the cost report to its contractor
for reimbursement determination.
Section 1874A of the Act describes
the functions of the contractor. CMHCs
must follow the principles of cost
reimbursement, which require they
maintain sufficient financial records
and statistical data for proper
determination of costs. The S series of
worksheets collects the provider’s
location, CBSA, date of certification,
operations, and unduplicated census
days. The A series of worksheets
collects the provider’s trial balance of
expenses for overhead costs, direct
patient care services, and non-revenue
generating cost centers. The B series of
worksheets allocates the overhead costs
to the direct patient care and nonrevenue generating cost centers using
functional statistical bases. The
Worksheet C computes the
apportionment of costs between
Medicare beneficiaries and other
patients. The D series of worksheets are
Medicare specific and calculate the
reimbursement settlement for services
rendered to Medicare beneficiaries. The
Worksheet F collects the provider’s
revenues and expenses data from the
provider’s income statement. Form
Number: CMS–2088–17 (OMB control
number: 0938–0378); Frequency:
Annually; Affected Public: Private
Sector, Business or other for-profits,
Not-for-profits institutions; Number of
Respondents: 184; Total Annual
Responses: 184; Total Annual Hours:
16,560. (For policy questions regarding
this collection contact Jill Keplinger at
410–786–4550.)
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8363
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Request For
Termination of Premium-Hospital and
or Supplementary Medical Insurance;
Use: Form CMS–1763 provides the
necessary information to process the
enrollee’s request for termination of Part
B and/or premium Part A coverage.
Sections 1818(c)(5), 1818A(c)(2)(B) and
1838(b)(1) of the Act and corresponding
regulations at 42 CFR 406.28(a) and
407.27(c) require that a Medicare
enrollee wishing to voluntarily
terminate Part B and/or premium Part A
coverage file a written request with CMS
or SSA. The statute and regulations also
specify when coverage ends based upon
the date the request for termination is
filed.
Form CMS–1763 collects the
information necessary to process
Medicare enrollment terminations. The
Request for Termination of Premium
Hospital and/or Supplementary Medical
Insurance (Form CMS–1763) provides a
standardized means to satisfy the
requirements of law, as well as allow
both agencies to protect the individual
from an inappropriate decision. Form
Number: CMS–1763 (OMB control
number: 0938–0025); Frequency:
Annually; Affected Public: State, Local,
or Tribal Governments; Number of
Respondents: 114,215; Total Annual
Responses: 114,215; Total Annual
Hours: 19,074. (For policy questions
regarding this collection contact Carla
Patterson at 410–786–1000.)
4. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Appointment of
Representative; Use: This form would be
completed by beneficiaries, providers
and suppliers (typically their billing
clerk, or billing company), and any
party who wish to appoint a
representative to assist them with their
initial Medicare claims determinations,
and filing appeals on Medicare claims.
The authority for collecting this
information is under 42 CFR 405.910(a)
of the Medicare claims appeal
procedures.
The information supplied on the form
is reviewed by Medicare claims and
appeals adjudicators. The adjudicators
make determinations whether the form
was completed accurately, and if the
form is correct and accepted, the form
is appended to the claim or appeal that
it pertains to. Form Number: CMS–1696
(OMB control number: 0938–0950);
Frequency: Annually; Affected Public:
Private Sector, Business or other forprofits; Number of Respondents:
270,544; Total Annual Responses:
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Federal Register / Vol. 86, No. 23 / Friday, February 5, 2021 / Notices
270,544; Total Annual Hours: 67,637.
(For policy questions regarding this
collection contact Katherine E. Hosna at
410–786–4993.)
Dated: February 2, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2021–02441 Filed 2–4–21; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Health Resources and Services
Administration
Agency Information Collection
Activities: Proposed Collection: Public
Comment Request Information
Collection Request Title: Federal Tort
Claims Act Program Deeming
Applications for Health Centers, OMB
No. 0906–0035 Extension
Health Resources and Services
Administration (HRSA), Department of
Health and Human Services.
ACTION: Notice.
AGENCY:
In compliance with the
requirement for opportunity for public
comment on proposed data collection
projects of the Paperwork Reduction Act
of 1995, HRSA announces plans to
submit an Information Collection
Request (ICR), described below, to the
Office of Management and Budget
(OMB). Prior to submitting the ICR to
OMB, HRSA seeks comments from the
public regarding the burden estimate,
below, or any other aspect of the ICR.
DATES: Comments on this Information
Collection Request must be received no
later than April 6, 2021.
ADDRESSES: Submit your comments to
paperwork@hrsa.gov or mail the HRSA
Information Collection Clearance
Officer, Room 14N136B, 5600 Fishers
Lane, Rockville, MD 20857.
SUMMARY:
To
request more information on the
proposed project or to obtain a copy of
the data collection plans and draft
instruments, email paperwork@hrsa.gov
or call Lisa Wright-Solomon, the HRSA
Information Collection Clearance Officer
at (301) 443–1984.
SUPPLEMENTARY INFORMATION: When
submitting comments or requesting
information, please include the
information request collection title for
reference.
Information Collection Request Title:
Federal Tort Claims Act Program
Deeming Applications for Health
Centers, OMB No. 0906–0035—
Extension.
Abstract: Section 224(g)–(n) of the
Public Health Service (PHS) Act (42
U.S.C. 233(g)–(n)), as amended,
authorizes the ‘‘deeming’’ of entities
receiving funds under section 330 of the
PHS Act as PHS employees for the
purpose of receiving Federal Tort
Claims Act (FTCA) coverage for the
performance of medical, surgical,
dental, and related functions for their
officers, board members, employees,
and certain contractors. The Health
Center Program is administered by
HRSA’s Bureau of Primary Health Care.
Health centers submit deeming
applications annually to HRSA in the
prescribed form and manner in order to
obtain deemed PHS employee status,
with the associated FTCA coverage.
Deemed PHS employment provides
the covered individual with immunity
from lawsuits and related civil actions
resulting from the performance of
medical, surgical, dental, and related
functions within the scope of deemed
employment.
The FTCA Program utilizes a web
based application system, the Electronic
Handbooks. The application includes
the following: Contact information;
Section 1: Review of Risk Management
Systems; Section 2: Quality
Improvement/Quality Assurance
Attestations; Section 3: Credentialing
and Privileging; Section 4: Claims
FOR FURTHER INFORMATION CONTACT:
Management; and Section 5: Additional
Information, Certification, and
Signatures.
HRSA is proposing no changes to the
Application for Health Center Program
Deemed Public Health Service
Employment Status information
collection request to be used for health
center deeming applications for
Calendar Year 2022 and thereafter.
Need and Proposed Use of the
Information: Deeming applications must
address certain specified criteria
required by law in order for deeming
determinations to be issued, and FTCA
application forms are critical to HRSA’s
deeming determination process. The
application submissions provide HRSA
with the information essential for
application evaluation and a deeming
determination for the purposes of FTCA
coverage. The application information is
also used to determine whether a site
visit is appropriate to assess issues
relating to the health center’s quality of
care and to determine technical
assistance needs.
Likely Respondents: Respondents
include Health Center Program funds
recipients seeking deemed PHS
employee status for purposes of FTCA
coverage.
Burden Statement: Burden in this
context means the time expended by
persons to generate, maintain, retain,
disclose or provide the information
requested. This includes the time
needed to review instructions; to
develop, acquire, install, and utilize
technology and systems for the purpose
of collecting, validating, and verifying
information, processing and
maintaining information, and disclosing
and providing information; to train
personnel and to be able to respond to
a collection of information; to search
data sources; to complete and review
the collection of information; and to
transmit or otherwise disclose the
information. The total annual burden
hours estimated for this ICR are
summarized in the table below.
TOTAL ESTIMATED ANNUALIZED BURDEN HOURS
Number of
respondents
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Form name
Number of
responses per
respondent
Total
responses
Average
burden per
response
(in hours)
Total burden
hours
Application for Health Center Program ................................
Deemed Public Health Service Employment Status (Initial)
Application for Health Center Program ................................
Deemed Public Health Service Employment Status (Redeeming) ...........................................................................
35
1
35
2.5
87.5
1,125
1
1,125
2.5
2,812.5
Total ..............................................................................
1,160
........................
1,160
........................
2,900
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18:53 Feb 04, 2021
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]]>Agencies
[Federal Register Volume 86, Number 23 (Friday, February 5, 2021)]
[Notices]
[Pages 8362-8364]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-02441]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers CMS-10203, CMS-2088-17, CMS-1763, and CMS-1696]
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 April 6, 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, 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 website address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
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-10203 Medicare Health Outcomes Survey
[[Page 8363]]
CMS-2088-17 Community Mental Health Center Cost Report
CMS-1763 Request For Termination of Premium-Hospital and or
Supplementary Medical Insurance
CMS-1696 Appointment of Representative
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: Revision of a currently
approved collection; Title of Information Collection: Medicare Health
Outcomes Survey (HOS); Use: The HOS is a longitudinal patient-reported
outcome measure (PROM) that assesses self-reported beneficiary quality
of life and daily functioning. As a PROM, the HOS measures the impact
of services provided by MAOs, whereas process and patient experience
measures only provide a snapshot of activities or experiences at a
specific point in time. PROM data collected by the HOS allows CMS to
continue to assess the health of the Medicare Advantage population.
This older population is at increased risk of adverse health outcomes,
including chronic diseases and mobility impairments that may
significantly hamper quality of life. The HOS supports CMS's commitment
to improve health outcomes for beneficiaries while reducing burden on
providers. CMS accomplishes this by focusing on high-priority areas for
quality measurement and improvement established in the agency's
Meaningful Measures Framework. The HOS uses quality measures that ask
beneficiaries about health outcomes related to specific mental and
Physical Conditions. Form Number: CMS-10203 (OMB control number: 0938-
0701); Frequency: Annually; Affected Public: Individuals and
Households; Number of Respondents: 1,485; Total Annual Responses:
629,280; Total Annual Hours: 201,370. (For policy questions regarding
this collection contact Debra Start at 410-786-6646.)
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Community Mental
Health Center Cost Report Use: CMS requires the Form CMS-2088-17 to
determine a provider's reasonable cost incurred in furnishing medical
services to Medicare beneficiaries and reimbursement due to or from a
provider. In addition, CMHCs may receive reimbursement through the cost
report for Medicare reimbursable bad debts. CMS uses the Form CMS-2088-
17 for rate setting; payment refinement activities, including market
basket analysis; Medicare Trust Fund projections; and to support
program operations. The primary function of the cost report is to
determine provider reimbursement for services rendered to Medicare
beneficiaries. Each CMHC submits the cost report to its contractor for
reimbursement determination.
Section 1874A of the Act describes the functions of the contractor.
CMHCs must follow the principles of cost reimbursement, which require
they maintain sufficient financial records and statistical data for
proper determination of costs. The S series of worksheets collects the
provider's location, CBSA, date of certification, operations, and
unduplicated census days. The A series of worksheets collects the
provider's trial balance of expenses for overhead costs, direct patient
care services, and non-revenue generating cost centers. The B series of
worksheets allocates the overhead costs to the direct patient care and
non-revenue generating cost centers using functional statistical bases.
The Worksheet C computes the apportionment of costs between Medicare
beneficiaries and other patients. The D series of worksheets are
Medicare specific and calculate the reimbursement settlement for
services rendered to Medicare beneficiaries. The Worksheet F collects
the provider's revenues and expenses data from the provider's income
statement. Form Number: CMS-2088-17 (OMB control number: 0938-0378);
Frequency: Annually; Affected Public: Private Sector, Business or other
for-profits, Not-for-profits institutions; Number of Respondents: 184;
Total Annual Responses: 184; Total Annual Hours: 16,560. (For policy
questions regarding this collection contact Jill Keplinger at 410-786-
4550.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Request For
Termination of Premium-Hospital and or Supplementary Medical Insurance;
Use: Form CMS-1763 provides the necessary information to process the
enrollee's request for termination of Part B and/or premium Part A
coverage. Sections 1818(c)(5), 1818A(c)(2)(B) and 1838(b)(1) of the Act
and corresponding regulations at 42 CFR 406.28(a) and 407.27(c) require
that a Medicare enrollee wishing to voluntarily terminate Part B and/or
premium Part A coverage file a written request with CMS or SSA. The
statute and regulations also specify when coverage ends based upon the
date the request for termination is filed.
Form CMS-1763 collects the information necessary to process
Medicare enrollment terminations. The Request for Termination of
Premium Hospital and/or Supplementary Medical Insurance (Form CMS-1763)
provides a standardized means to satisfy the requirements of law, as
well as allow both agencies to protect the individual from an
inappropriate decision. Form Number: CMS-1763 (OMB control number:
0938-0025); Frequency: Annually; Affected Public: State, Local, or
Tribal Governments; Number of Respondents: 114,215; Total Annual
Responses: 114,215; Total Annual Hours: 19,074. (For policy questions
regarding this collection contact Carla Patterson at 410-786-1000.)
4. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Appointment of
Representative; Use: This form would be completed by beneficiaries,
providers and suppliers (typically their billing clerk, or billing
company), and any party who wish to appoint a representative to assist
them with their initial Medicare claims determinations, and filing
appeals on Medicare claims. The authority for collecting this
information is under 42 CFR 405.910(a) of the Medicare claims appeal
procedures.
The information supplied on the form is reviewed by Medicare claims
and appeals adjudicators. The adjudicators make determinations whether
the form was completed accurately, and if the form is correct and
accepted, the form is appended to the claim or appeal that it pertains
to. Form Number: CMS-1696 (OMB control number: 0938-0950); Frequency:
Annually; Affected Public: Private Sector, Business or other for-
profits; Number of Respondents: 270,544; Total Annual Responses:
[[Page 8364]]
270,544; Total Annual Hours: 67,637. (For policy questions regarding
this collection contact Katherine E. Hosna at 410-786-4993.)
Dated: February 2, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2021-02441 Filed 2-4-21; 8:45 am]
BILLING CODE 4120-01-P
