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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Federal Register / Vol. 78, No. 193 / Friday, October 4, 2013 / Notices 61847 

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 evaluate 

prescription 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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61848 Federal Register / Vol. 78, No. 193 / Friday, October 4, 2013 / Notices 

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 delivery 

models (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. 


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