[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]


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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.

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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 __, 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