### 61846 Federal Register/ Vol. 78, No. 193 / Friday, October 4, 2013 / Notices

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Centers for Medicare & Medicaid**
**Services**

**[Document Identifiers: CMS–2746, CMS– 2728, CMS–P–0015A, CMS–43, CMS–10137,**  **CMS–10156, CMS–10170, CMS–10237, CMS–10261, CMS–10326, and CMS–10493]** 

**Agency Information Collection**
**Activities: Submission for OMB Review; Comment Request** 

**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 (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 a second opportunity for public
comment on the notice. Interested persons are invited to send comments regarding the burden estimate 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 on the collection(s) of information must be received by the OMB desk officer by November 4, 2013.

**ADDRESSES :**  When commenting on the proposed information collections, please reference the document identifier
or OMB control number. To be assured consideration, comments and recommendations must be received by
the OMB desk officer via one of the following transmissions: OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax Number: (202) 395–6974 OR Email:

OIRA

_submission@omb.eop.gov.

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 :**  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 previously approved collection; Title of Information Collection: End Stage Renal Disease Death Notification; Use: The End Stage Renal Disease (ESRD) Death Notification (CMS–2746) is completed by all Medicare-approved ESRD facilities upon the death of an ESRD patient. Its primary purpose is to collect
fact of death and cause of death of ESRD patients. Certain other identifying information (e.g., name, Medicare claim number, and date of birth) is required for matching purposes. federal regulations require that the ESRD Networks examine the mortality rates of every Medicare-approved facility within its area of responsibility. The death form provides the necessary data to assist the ESRD Networks in making decisions that result in improved patient care and
in cost-effective distribution of ESRD resources. The data is used by the ESRD Networks to verify facility deaths and to monitor facility performance. Form
Number: CMS–2746 (OCN: 0938–0448); Frequency: On occasion;Affected
Public: Business or other for-profit and Not-for-profit institutions; Number of Respondents: 5,964; Total Annual Responses: 75,000; Total Annual Hours: 37,500. (For policy questions regarding this collection contact Michelle Tucker at 410–786–0736.)

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: End Stage Renal Disease Medical Evidence Report
Medicare Entitlement and/or Patient Registration; Use: The End Stage Renal Disease (ESRD) Medical Evidence Report is completed for all ESRD patients either by the first treatment facility or by a Medicare-approved ESRD facility when it is determined by a physician that the patient’s condition has reached that stage of renal impairment that a regular course of kidney dialysis or a kidney transplant is necessary to maintain life. The data reported on the CMS–2728 is used by the Federal government, ESRD Networks, treatment facilities,
researchers and others to monitor and assess the quality and type of care provided to end stage renal disease
beneficiaries. The data collection captures the specific medical information required to determine the Medicare medical eligibility of End Stage Renal Disease claimants. Form
Number: CMS–2728 (OCN: 0938–0046); Frequency: Occasionally; Affected
Public: Individuals or households; Number of Respondents: 130,000; Total Annual Responses: 130,000; Total
Annual Hours: 97,500. (For policy questions regarding this collection
contact Michelle Tucker at 410–786– 0736.)

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Medicare Current Beneficiary Survey; Use: We are the largest single payer of health care in
the United States. With full implementation of the Affordable Care Act of 2010 (ACA), the agency will play a direct or indirect role in administering health insurance coverage for more than 120 million people across the Medicare, Medicaid, CHIP, and Exchange populations. One of our critical aims is to be an effective steward, major force, and trustworthy partner in leading the
transformation of the health care system. We also aim to provide Americans with high quality care and better health at lower costs through improvement. At the forefront of these initiatives is the newly formed Center
for Medicare and Medicaid Innovation (CMMI).

The CMMI is authorized by Section 1115A of the Social Security Act, as established by section 3021 of the ACA
and was established to ‘‘test innovative payment and service delivery models to reduce program expenditures . . . while


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preserving or enhancing the quality of care furnished’’ to Medicare, Medicaid and CHIP beneficiaries. Implicit across all of CMMI activities is an emphasis on diffusion—finding and validating
innovative models that have the potential to scale, facilitating rapid adoption, and letting them take root in organizations, health systems, and

communities across America.

The Medicare Current Beneficiary Survey (MCBS) is the most comprehensive and complete survey available on the Medicare population and is essential in capturing data not otherwise collected through our operations. The MCBS is an in-person, nationally-representative, longitudinal survey of Medicare beneficiaries that we sponsor and is directed by the Office of
Information Products and Data Analytics (OIPDA) in partnership with the CMMI. The survey captures beneficiary information whether aged or disabled, living in the community or facility, or serviced by managed care or fee-for-service. Data produced as part of
the MCBS are enhanced with our administrative data (e.g. fee-for-service claims, prescription drug event data, enrollment, etc.) to provide users with more accurate and complete estimates of
total health care costs and utilization. The MCBS has been continuously fielded for more than 20 years (encompassing over 1 million interviews), and consists of three annual interviews per survey participant.

The MCBS continues to provide unique insight into the Medicare program and helps both us and our
external stakeholders better understand and evaluate the impact of existing programs and significant new policy initiatives. In the past, MCBS data have been used to assess potential changes to the Medicare program. For example, the MCBS was instrumental in supporting the development and implementation of the Medicare prescription drug benefit by providing a means to evaluateprescription drug costs and out-ofpocket burden for these drugs to
Medicare beneficiaries. Form Number: CMS–P–0015A (OCN: 0938–0568); Frequency: Occasionally;Affected
Public: Business or other for-profits and Not-for-profit institutions; Number of Respondents: 16,550; Total Annual Responses: 49,650; Total Annual Hours: 58,450 (For policy questions regarding this collection contact William Long at 410–786–7927.)

4. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease; Use: The CMS–43 application is used (in conjunction with CMS–2728) to establish entitlement to, and enrollment in, Medicare Part A (and Part B) for individuals with end stage renal disease. The application is completed by a Social Security Administration (SSA) claims representative or field representative using information provided by the individual during an interview. The CMS–43 application follows the questions and requirements used by SSA to determine Title II eligibility. This is done not only for consistency purposes, but because certain Title II
and Title XVIII insured status and relationship requirements must be met in order to qualify for Medicare under the end stage renal disease provisions.
Form Number: CMS–43 (OCN: 0938– 0800); Frequency: Once; Affected
Public: Individuals or households; Number of Respondents: 60,000; Total Annual Responses: 60,000; Total
Annual Hours: 24,960. (For policy questions regarding this collection contact Lindsay Smith at 410–786– 6843.)

5. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Solicitation for Applications for Medicare Prescription Drug Plan 2015 Contracts; Use: The
information will be collected under the solicitation of proposals from prescription drug plans, Medicare Advantage (MA) plans that offer integrated prescription drug and health care coverage, Cost Plans, PACE, and EGWP applicants. We will use the
information collected to ensure that applicants meet our requirements and to support the determination of contract
awards. Form Number: CMS–10137 (OCN: 0938–0936); Frequency: Yearly; Affected Public: Business or other forprofits and Not-for-profits institutions; Number of Respondents: 254; Total Annual Responses: 254; Total Annual

Hours: 2,319. (For policy questions regarding this collection contact Linda Anders at 410–786–0459.)

6. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Retiree Drug Subsidy (RDS) Applications and
Instructions; Use: Under the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 and implementing regulations at 42 CFR part 423, subpart R plan sponsors (e.g., employers, unions) who offer prescription drug coverage to their qualified covered retirees are eligible to receive a 28 percent tax-free subsidy for allowable drug costs. In order to qualify, plan sponsors must submit a complete application with a list of retirees for whom it intends to collect the subsidy. Once we review and analyze the information on the application and the retiree list, notification will be sent to the plan sponsor about its eligibility to participate in the RDS program. Form
Number: CMS–10156 (OCN: 0938– 0957); Frequency: Yearly and monthly; Affected Public: Business or other forprofits and Not-for-profit institutions; Number of Respondents: 4,500; Total Annual Responses: 4,500; Total Annual

Hours: 288,000. (For policy questions regarding this collection contact John W. Campbell at 410–786–0542.)

7. Type of Information Collection Request: Reinstatement without change of a previously approved collection; Title of Information Collection: Retiree Drug Subsidy (RDS) Payment Request and Instructions; Use: Under section 1860D–22 of the Social Security Act and implementing regulations at 42 CFR part 423 subpart R, plan sponsors (e.g., employers, unions) who offer prescription drug coverage meeting specified criteria to their qualified covered retirees are eligible to receive a 28 percent tax-free subsidy for allowable drug costs. Plan sponsors must submit required prescription drug cost data and
other information in order to receive the subsidy. Subpart R stipulates that plan sponsors may elect to submit RDS payment requests on a monthly, quarterly, interim annual, or annual basis; once selected, the payment frequency may not be changed during the plan year. Form Number: CMS– 10170 (OCN: 0938–0977); Frequency: Occasionally; Affected Public: Business or other for-profits and Not-for-profit
institutions; Number of Respondents:

4,500; Total Annual Responses: 4,500; Total Annual Hours: 679,500. (For policy questions regarding this collection contact John W. Campbell at 410–786–0542.)

8. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Part C— Medicare Advantage and 1876 Cost Plan Expansion Application; Use: Organizations wishing to provide
healthcare services under Medicare Advantage (MA), MA–PD or both that offer integrated prescription drug and health care products must complete an application, file a bid, and receive final approval from us. Existing MA plans may request to expand their contracted service area by completing the Service Area Expansion application. Any
current 1876 Cost Plan Contractor that wants to expand its Medicare cost-based contract with us can complete the


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application. Information is collected to ensure applicant compliance with our requirements and to gather data used to support its determination of contract
awards. Form Number: CMS–10237 (OCN 0938–0935); Frequency: Yearly; Affected Public: Business or other forprofits and Not-for-profits institutions; Number of Respondents: 566; Total Annual Responses: 566; Total Annual

Hours: 22,955. (For policy questions regarding this collection contact Melissa Staud at 410–786–3669.)

9. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Part C Medicare Advantage Reporting Requirements and Supporting Regulations; Use: There are
a number of information users of Part C reporting data, including our central and regional office staff that use this information to monitor health plans and
to hold them accountable for their performance, researchers, and other government agencies such as the Government Accounting Office. Health plans can use this information to
measure and benchmark their performance. We intend to make some of these data available for public reporting as ‘‘display measures’’ in

2013. Form Number: CMS–10261 (OCN: 0938–1054); Frequency: Yearly and semi-annually; Affected Public: Business or other for-profits; Number of Respondents: 588; Total Annual Responses: 6,715; Total Annual Hours: 174,785. (For policy questions regarding this collection contact Terry Lied at 410–786–8973.)

10. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Electronic
Submission of Medicare Graduate Medical Education (GME) Affiliation Agreements; Use: We use the
information contained in electronic affiliation agreements as documentation
of the existence of Medicare GME affiliations, and to verify that the affiliations being formed by teaching hospitals for the purposes of sharing
their Medicare Graduate Medical Education FTE cap slots are valid according to our regulations. The affiliation agreements are also used as reference materials when potential issues involving specific affiliations

arise. Form Number: CMS–10326 (OCN: 0938–1111); Frequency: Yearly; Affected
Public: Business or other for-profits and Not-for-profit institutions; Number of Respondents: 125; Total Annual Responses: 125; Total Annual Hours: 166. (For policy questions regarding this
collection contact Tzvi Hefter at 410– 786–0614.) 11. Type of Information Collection Request: New collection (request for a new OMB control number); Title of Information Collection: Nationwide
Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid; Use: The goal of the survey is to obtain national and state-by-state estimates of adult
Medicaid beneficiaries’ access and experiences and satisfaction with care across different financing and deliverymodels (e.g., managed care and fee-forservice) and population groups (e.g., beneficiaries with physical, mental or both physical and mental disabilities, dually eligible beneficiaries, all other beneficiaries). The survey will serve as baseline information on the experiences of low-income adults during the early stages of implementation of the Affordable Care Act provision that permits states to expand eligibility to adults with income below 138 percent of the Federal poverty level who were not previously eligible. Along with states, we can use the survey
information as one indicator of the quality of care within and across states. It also will be used to assist us along with the states in efforts to provide
better care and more affordable care to
Medicaid beneficiaries. Form Number: CMS–10493 (OCN: 0938–New); Frequency: Once; Affected Public: Individuals and households; Number of Respondents: 1,500,000; Total Annual Responses: 510,000; Total Annual

Hours: 170,000. (For policy questions regarding this collection contact Marsha Lillie-Blanton at 410–786–8856.)

Dated: September 30, 2013.
Martique Jones, Deputy Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2013–24219 Filed 10–3–13; 8:45 am]

**BILLING CODE 4120–01–P**

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Centers for Medicare & Medicaid**
**Services**

**[Document Identifiers: CMS–37, CMS–64, CMS–10052, CMS–10141, CMS–10142,**  **CMS–10227, CMS–10311, CMS–10344, CMS–10500, CMS–R–26, CMS–R–138, CMS–**  **R–244, and CMS–R–308]**

**Agency Information Collection Activities: Proposed Collection;**  **Comment Request**

**AGENCY :**  Centers for Medicare & Medicaid 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 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 December 3, 2013:

**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

lll, 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.