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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services

          - [Document Identifiers CMS-10410, CMS-R-74, CMS-2552-10 and CMS-855R]

# AGENCY:

Centers for Medicare & Medicaid Services.

# 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 any of the following subjects: (1) The necessity and utility of the proposed information collection for the proper performance of the agency's functions; (2) the accuracy of the estimated burden; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) 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 7, 2015.*

# ADDRESSES:

When commenting, please reference the document identifier or OMB control number (OCN). 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' Web site address at                         *http://www.cms.hhs.gov/​PaperworkReductionActof1995.*

                        2. Email your request, including your address, phone number, OMB number, and CMS document identifier, to                         *Paperwork@cms.hhs.gov.*

3. Call the Reports Clearance Office at (410) 786-1326.

# FOR FURTHER INFORMATION CONTACT:

Reports Clearance Office at (410) 786-1326.

# 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-10410 Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010

CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regulations

CMS-2552-10 Hospital and Hospital Health Care Complex Cost Report

CMS-855R Medicare Enrollment Application: Reassignment of Medicare Benefits

                    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                           ( print page 6727)                        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:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010;                     *Use:*                     The eligibility systems are essential to the goal of increasing coverage in insurance affordability programs while reducing administrative burden on states and consumers. The electronic transmission and automation of data transfers are key elements in managing the expected insurance affordability program caseload that started in 2014. Accomplishing the same work without these information collection requirements would not be feasible.                     *Form Number:*                     CMS-10410 (OMB control number 0938-1147);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     Individuals or households, and State, Local, and Tribal Governments;                     *Number of Respondents:*                     25,500,096;                     *Total Annual Responses:*                     76,500,149;                     *Total Annual Hours:*                     21,278,142. (For policy questions regarding this collection contact Brenda Sheppard at 410-786-8534).                

                    2.                     *Type of Information Collection Request:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Income and Eligibility Verification System Reporting and Supporting Regulations;                     *Use:*                     A state Medicaid agency that currently obtains and uses information from certain sources, or with more frequency than specified, could continue to do so to the extent that the verifications are useful and not redundant. An agency that has found it effective to verify all wage or benefit information with another agency or with the recipient is encouraged to continue these practices if it chooses. On the other hand, the agency may implement an approved targeting plan under 42 CFR 435.953. The agency's experience should guide its decision whether to exceed these regulatory requirements on income and eligibility verification. While states may target resources when verifying income of course, agencies are still held accountable for their accuracy in eligibility determinations.                     *Form Number:*                     CMS-R-74 (OMB control number 0938-0467);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     50;                     *Total Annual Responses:*                     71;                     *Total Annual Hours:*                     134,865. (For policy questions regarding this collection contact Brenda Sheppard at 410-786-8534).                

                    3.                     *Type of Information Collection Request:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     Hospital and Hospital Health Care Complex Cost Report;                     *Use:*                     Providers of services participating in the Medicare program are required under sections 1815(a) and 1861(v)(1)(A) of the Social Security Act (42 U.S.C. 1395g) to submit annual information to achieve settlement of costs for health care services rendered to Medicare beneficiaries. In addition, regulations at 42 CFR 413.20 and 413.24 require adequate cost data and cost reports from providers on an annual basis.                

                    We are requesting the Office of Management and Budget review and approve this revision to the Form CMS-2552-10, Hospital and Hospital Health Care Complex Cost Report. These cost reports are filed annually by hospitals participating in the Medicare program to determine the reasonable costs incurred to provide medical services to patients. The revisions made to the hospital cost report are in accordance with the statutory requirement for hospice payment reform in § 3132 of the Patient Protection and Affordable Care Act (ACA) (March 23, 2010) and the statutory requirement establishing a prospective payment system for Federally Qualified Health Centers in § 10501(i)(3)(A) of the ACA, codified in section 1834(o) of the Act.                     *Form Number:*                     CMS-2552-10 (OMB control number 0938-0050);                     *Frequency:*                     Yearly;                     *Affected Public:*                     State, Local, or Tribal Governments, private sector (for-profit and not-for-profit institutions);                     *Number of Respondents:*                     6,157;                     *Total Annual Responses:*                     6,157;                     *Total Annual Hours:*                     4,143,661. (For policy questions regarding this collection contact Gail Duncan at 410-786-7278).                

                    4.                     *Type of Information Collection Request:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     Medicare Enrollment Application: Reassignment of Medicare Benefits;                     *Use:*                     The primary function of the CMS 855R enrollment application is to allow physicians and non-physician practitioners to reassign their Medicare benefits to a group practice and to gather information from the individual that tells us who he/she is, where he or she renders services, and information necessary to establish correct claims payment. The goal of periodically evaluating and revising the CMS 855R enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information.                

                    At this time, CMS is making very few minor revisions to the CMS 855R (Reassignment of Benefits) Medicare enrollment application (OMB No. 0938-1179). Two sections within the form are being reversed to maintain sync with online and paper forms. The previously approved CMS 855R section 2 collected information regarding the individual practitioner who is reassigning benefits and section 3 collected information regarding the organization/group receiving the reassigned benefits. These two sections have been reversed so that section 2 now collects information on the regarding the organization/group receiving the reassigned benefits and section 3 now collects information on the individual practitioner who is reassigning benefits. No information or data collection within these sections was revised. The sections were merely re-sequenced and re-numbered to maintain sync between online and paper forms. With the exception of this section reversal and adding the word “optional” to sections 4 and 5 (primary practice location and contact person information), there are no other revisions. These revisions offer no new data collection in this revision package. The addition of the optional choice in sections 4 and 5 could potentially reduce the burden to providers who choose not to complete either or both optional sections.                     *Form Number:*                     CMS-855R (OMB control number 0938-1179);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     State, Local, or Tribal Governments, private sector (for-profit and not-for-profit institutions);                     *Number of Respondents:*                     379,619;                     *Total Annual Responses:*                     379,619;                     *Total Annual Hours:*                     94,905. (For policy questions regarding this collection contact Kim McPhillips at 410-786-5374).                

Dated: February 3, 2015.

William N. Parham, III,

Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2015-02414 Filed 2-5-15; 8:45 am]

BILLING CODE 4120-01-P