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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:

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 __, 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                          ( print 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:*      ( print 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