### 45203 Federal Register / Vol. 78, No. 144 / Friday, July 26, 2013 / Notices

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

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

**[Document Identifiers CMS–R–13, CMS–R– 297, CMS–10088, CMS–10293, CMS–10477,**  **CMS–855(POH), CMS–2552–10, CMS–10185 and CMS–10463]** 

**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 August 26, 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: Reinstatement with change of a previously approved collection; Title of Information Collection: Conditions of Coverage for Organ Procurement Organizations and Supporting Regulations; Use: Section 1138(b) of the Social Security Act, as added by section 9318 of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99– 509), sets forth the statutory qualifications and requirements that organ procurement organizations (OPOs) must meet in order for the costs of their services in procuring organs for transplant centers to be reimbursable
under the Medicare and Medicaid programs. An OPO must be certified and designated by the Secretary as an OPO and must meet performance-related standards prescribed by the Secretary. The corresponding regulations are found at 42 CFR Part 486 (Conditions for Coverage of Specialized Services Furnished by Suppliers) under subpart G (Requirements for Certification and Designation and Conditions for Coverage: Organ Procurement Organizations).

Since each OPO has a monopoly on organ procurement within its designated service area (DSA), we must hold OPOs to high standards. Collection of this information is necessary for us to assess
the effectiveness of each OPO and
determine whether it should continue to be certified as an OPO and designated for a particular donation service area by the Secretary or replaced by an OPO that can more effectively procure organs
within that DSA. Form Number: CMS– R–13 (OCN: 0938–0688); Frequency: Occasionally; Affected Public: Private sector—Not-for-profit institutions; Number of Respondents: 58; Total Annual Responses: 58; Total Annual

Hours: 14,453. (For policy questions regarding this collection contact Diane Corning at 410–786–8486.)

2. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: Request for Employment Information; Use: The Social Security Administration uses this
form to obtain information from employers regarding whether a Medicare beneficiary’s coverage under a group health plan is based on current employment status. Form Number: CMS–R–297 (OCN: 0938–0787); Frequency: Once; Affected Public:
Private sector—Business or other forprofit and Not-for-profit institutions; Number of Respondents: 15,000; Total Annual Responses: 15,000; Total
Annual Hours: 3,750. (For policy questions regarding this collection contact Lindsay Smith at 410–786– 6843.)

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Notification of Fiscal Intermediaries (FIs) and CMS of
Co-located Medicare Providers and Supporting Regulations; Use: Manylong-term care hospitals (LTCHs) are colocated with other Medicare providers (acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and psychiatric facilities), which leads to potential gaming of the Medicare system based on patient shifting. We require that LTCHs notify FIs, Medicare administrative contractors (MACs), and CMS of co-located providers and establish policies to limit payment abuse that will be based on FIs and MACs tracking patient movement among these co-located providers under 42 CFR 412.22(e)(6) and (h)(5).


### 45204 Federal Register / Vol. 78, No. 144 / Friday, July 26, 2013 / Notices

Based upon being able to identify colocated providers, FIs, MACs, and CMS will be able to track patient shifting between LTCHs and other in-patient providers which will lead to appropriate payments under § 412.532. That section limits payments to LTCHs where over 5 percent of admissions represent patients who had been sequentially discharged by the LTCH, admitted to an on-site provider, and subsequently readmitted to the LTCH. Since each discharge triggers a Medicare payment, we implemented this policy to discourage payment abuse. Form Number: CMS– 10088 (OCN: 0938–0897); Frequency: Occasionally; Affected Public: Private sector—Business or other for-profit and Not-for-profit institutions; Number of Respondents: 25; Total Annual Responses: 25; Total Annual Hours: 6. (For policy questions regarding this collection contact Judy Richter at 410– 786–2590.)

4. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Tribal
Consultation State Plan Amendment Template; Use: Certain states utilize a process to seek advice on a regular ongoing basis from designees of the Indian Health Service (IHS) and Urban Indian Organizations concerning
Medicaid and Children’s Health Insurance Program (CHIP) matters having a direct effect on them. The consultation process is required for the
37 states in which 1 or more Indian Health Programs or Urban Indian Organizations furnish health care services. The states’ Medicaid agency will complete the template page and submit it for approval as part of its state plan amendment. The purpose is to
document how the state meets the tribal consultation requirements. Form Number: CMS–10293 (OCN: 0938– 1098); Frequency: Occasionally; Affected Public: State, Local, or Tribal Governments; Number of Respondents:

37; Total Annual Responses: 37; Total
Annual Hours: 37. (For policy questions regarding this collection contact Lane Terwilliger at 410–786–6618.)

5. Type of Information Collection Request) New Collection (Request for a new control number); Title of Information Collection: Medicaid
Incentives for Prevention of Chronic Disease (MIPCD) Demonstration; Use: Under section 4108(d)(1) of the Affordable Care Act, we are required to contract with an independent entity or organization to conduct an evaluation of
the Medicaid Incentives for Prevention of Chronic Disease (MIPCD)
demonstration. The contractor will conduct state site visits, two rounds of focus group discussions, interviews with key program stakeholders, and field a beneficiary satisfaction survey.
Both the state site visits and interviews with key program stakeholders will entail one-on-one interviews; however each set will have a unique data collection form. Thus, each evaluation task listed above has a separate data collection form and this proposed information collection encompasses four data collection forms. The purpose
of the evaluation and assessment includes determining the following:

• The effect of such initiatives on the use of health care services by Medicaid beneficiaries participating in the

program;

• The extent to which special populations (including adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program;

• The level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and

• The administrative costs incurred by state agencies that are responsible for administration of the program.

Form Number: CMS–10477 (OCN: 0938–NEW); Frequency: Annually; Affected Public: Individuals and households, Business or other for-profits and Not-for-profit institutions, State, Local or Tribal Governments; Number of Respondents: 4,524; Total Annual Responses: 4,524; Total Annual Hours: 1,795. (For policy questions regarding this collection contact Jean Scott at 410– 786–6327.)

6. Type of Information Collection Request: New collection (Request for a new OMB control number); Title of Information Collection: Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest;

Use: Section 6001 of the Affordable Care Act (ACA) requires Medicare hospitals to report whether they have any physician owners including immediately family members of the physician. Currently the CMS 855A captures basic ownership and managerial information on providers. The CMS 855A was revised in July 2011 and a specific attachment designed to capture physician-owned hospital ownership and investment interest data
was added to the form. The attachment is being removed from the CMS 855A application because the annualreporting requirement for physicianowned hospitals is not required for Medicare enrollment processing. This physician-owned hospital data collection is mandated to be reported on an annual basis. Additionally, the ACA prohibits the expansion of current physician-owned hospitals and banned the establishment of new ones making the CMS 855A the improper method to collect this required annual report.

We are requesting the physicianowned hospital ownership information, investment information or both, previously collected in Attachment 1 of the CMS 855A enrollment application to
become a stand-alone form with a unique OMB number for the following

reasons:

• The physician-owned data collection has a small targeted audience of approximately 140 physician-owned hospitals nationwide.

• The physician-owned data collection is required annually, as noted
above.

• The data required under section 6001 is more specific than the data currently collected on the CMS–855A provider enrollment application.

• The data is not required for Medicare provider enrollment purposes.

Form Number: CMS–855 (POH)(OCN: 0938–New); Frequency: Yearly; Affected
Public: Private Sector—Business or other for-profits and Not-for-profit institutions; Number of Respondents:

140; Total Annual Responses: 140; Total
Annual Hours: 140. (For policy questions regarding this collection contact Kim McPhillips at 410–786– 5374.)

7. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Hospital and Health Care Complexes and Supporting Regulations in 42 CFR 413.20 and

413.24; Use: Medicare Part A institutional providers must provide adequate cost data to receive Medicare reimbursement (42 CFR 413.24(a)).
Providers must submit the cost data to their Medicare Fiscal Intermediary (FI)/
Medicare Administrative Contractor (MAC) through the Medicare cost report (MCR). We are submitting a revision of the Hospital and Hospital Health Care Complex Cost Report, Form CMS–2552– 10. Form CMS 2552–10 is used by hospitals participating in the Medicare program to report the health care costs
to determine the amount of
reimbursable costs for services rendered
to Medicare beneficiaries. The revisions were caused by legislative requirements
in the Patient Protection and Affordable Care Act of 2010 and the Temporary Payroll Tax Cut Continuation Act of

2011. Form Number: CMS–2552–10 (OCN: 0938–0050); Frequency: Yearly; Affected Public: Private sector—Business or other for-profits and Notfor-profit institutions; Number of


### 45205 Federal Register / Vol. 78, No. 144 / Friday, July 26, 2013 / Notices

Respondents: 6,171; Total Annual Responses: 6,171; Total Annual Hours: 4,153,083. (For policy questions regarding this collection contact Nadia Massuda at 410–786–5834.)

8. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Medicare Part D Reporting Requirements; Use: Title I, Part 423, § 423.514 describes our regulatory authority to establish reporting requirements for Part D sponsors. It is noted that each Part D plan sponsor must have an effective procedure to develop, compile, evaluate, and report to us, to its enrollees, and to the general public, at
the times and in the manner that we requires, statistics in the following areas: the cost of its operations; the patterns of utilization of its services; the availability, accessibility, and acceptability of its services; information demonstrating that the Part D plan sponsor has a fiscally sound operation; and other matters that we may require. CMS has identified the appropriate data needed to effectively monitor plan performance. Changes to the currently approved data collection instrument reflect new executive orders, legislation, as well as recent changes to Agency policy and guidance. Form Number: CMS–10185 (OCN: 0938–0992); Frequency: Occasionally; Affected
Public: Business and other for-profits; Number of Respondents: 690; Total Annual Responses: 8,067; Total Annual

Hours: 12,658. (For policy questions regarding this collection contact Latoyia Grant at 410–786–5434.)

9. Type of Information Collection Request: New collection (Request for a new OMB control number); Title of Information Collection: Cooperative Agreement to Support Navigators in Federally-facilitated and State Partnership Exchanges; Use: Section 1311(i) of the Affordable Care Act requires Exchanges to establish a Navigator grant program as part of its function to provide consumers with assistance when they need it. Navigators will assist consumers by providing education about and facilitating selection of qualified health plans (QHPs) within Exchanges, as well as other required duties. Section 1311(i) requires that an Exchange operating as of January 1, 2014, must establish a Navigator Program under which it awards grants to eligible individuals or entities who satisfy the requirements tobe Exchange Navigators. For Federallyfacilitated Exchanges (FFE) and State Partnership Exchanges (SPEs), we will be awarding the grants. Navigatorawardees must provide quarterly, biannual, and an annual progress report to us on the activities performed during the grant period and any sub-awardees receiving funds. The 60-day Federal Register notice was published on April 12, 2013 (78 FR 21957). Several commenters suggested changes to the reporting requirements which were incorporated where appropriate. Form Number: CMS–10463 (OCN: 0938– NEW); Frequency: Annually, Quarterly; Affected Public: Private sector; Number of Respondents: 264; Total Annual Responses: 1,848; Total Annual Hours: 308,352. (For policy questions regarding this collection contact Holly Whelan at 301–492–4220.)

Dated: July 23, 2013.
Martique Jones, Deputy Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2013–18004 Filed 7–25–13; 8:45 am]

**BILLING CODE 4120–01–P**

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

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

**[Document Identifiers: CMS–10326, CMS– 10487, CMS–P–0015A, CMS–R–10, CMS–R–**  **240, CMS–10282, CMS–R–65 and CMS– 10491]** 

**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 September 24, 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

____, 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–10326 Electronic Submission of

Medicare Graduate Medical Education (GME) Affiliation Agreements CMS–10487 Medicaid Emergency

Psychiatric Demonstration (MEPD)
Evaluation
CMS–P–0015A Medicare Current

Beneficiary Survey CMS–R–10 Advance Directives (Medicare

and Medicaid) and Supporting Regulations