8362 Federal Register / Vol. 86, No. 23 / Friday, February 5, 2021 / 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 

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 

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 http://

www.regulations.gov. Follow the 

instructions for ‘‘Comment or 

Submission’’ or ‘‘More Search Options’’ 

to find the information collection 

document(s) that are accepting 

comments. 

2. By regular mail. You may mail 

written comments to the following 

address: CMS, Office of Strategic 

Operations and Regulatory Affairs, 

Division of Regulations Development, 

Attention: Document Identifier/OMB 

Control Number 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 


jbell on DSKJLSW7X2PROD with NOTICES
Federal Register / Vol. 86, No. 23 / Friday, February 5, 2021 / Notices 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 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 

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.) 

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: 


jbell on DSKJLSW7X2PROD with NOTICES
8364 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 

AGENCY: Health Resources and Services 

Administration (HRSA), Department of 

Health and Human Services. 

ACTION: Notice. 

SUMMARY: 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. 

FOR FURTHER INFORMATION CONTACT: 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 

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

Form name Number of 

respondents 

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) 35 1 35 2.5 87.5 

Application for Health Center Program ................................

Deemed Public Health Service Employment Status (Redeeming) ........................................................................... 1,125 1 1,125 2.5 2,812.5 

Total .............................................................................. 1,160 ........................ 1,160 ........................ 2,900 


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