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

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: Many 

long-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). 


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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 annual 

reporting 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 


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

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 to 

be Exchange Navigators. For Federallyfacilitated Exchanges (FFE) and State 

Partnership Exchanges (SPEs), we will 

be awarding the grants. Navigator 

awardees 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 


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