12456 Federal Register / Vol. 87, No. 43 / Friday, March 4, 2022 / Notices 

Colorado; and Vandy Sears, Cheyenne, 

Wyoming; to become members of the 

Wiens Family Group, a group acting in 

concert, to acquire voting shares of 

FirsTier II Bancorp., Cheyenne, 

Wyoming, and thereby indirectly 

acquire voting shares of FirsTier Bank, 

Kimball, Nebraska. 

In addition, Jan Wiens, Westminster, 

Colorado; T. Jordan Wiens, Broomfield, 

Colorado; Lindsey Sears, Cheyenne, 

Wyoming; Diana Wiens and Travis 

Wiens, both of Sedalia, Colorado; 

Lauren Bocci, Erie, Colorado; Hannah 

Nelson, Ellisville, Missouri; Sarah Swor, 

Chico, Texas; and Terry Wiens, 

Edmond, Oklahoma; to become 

members of the Wiens Family Group, 

and with Timothy D. Wiens and 

Thomas J. Wiens, to retain voting shares 

of FirsTier II Bancorp., and thereby 

indirectly retain shares of FirsTier Bank. 

2. The Alice M. Dittman 2011 

Irrevocable Trust, John F. Dittman, as 

trustee, and Susan G. Dittman, all of 

Lincoln, Nebraska; to join the Dittman 

Family Group, a group acting in concert, 

to retain voting shares of Cornhusker 

Growth Corporation, and thereby 

indirectly retain voting shares of 

Cornhusker Bank, both of Lincoln, 

Nebraska 

Board of Governors of the Federal 

Reserve System, March 1, 2022. 

Michele Taylor Fennell, 

Deputy Associate Secretary of the Board. 

[FR Doc. 2022–04647 Filed 3–3–22; 8:45 am] 

BILLING CODE 6210–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–367a–e, CMS– 

10330, CMS–10780, CMS–10524 and CMS– 

906] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services, Health and Human 

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 

(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 the necessity and 

utility of the proposed information 

collection for the proper performance of 

the agency’s functions, the accuracy of 

the estimated burden, ways to enhance 

the quality, utility, and clarity of the 

information to be collected, and 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 April 4, 2022. 

ADDRESSES: Written comments and 

recommendations for the proposed 

information collection should be sent 

within 30 days of publication of this 

notice to www.reginfo.gov/public/do/ 

PRAMain. Find this particular 

information collection by selecting 

‘‘Currently under 30-day Review—Open 

for Public Comments’’ or by using the 

search function. 

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’ website address at 

website address at: https://

www.cms.gov/Regulations-andGuidance/Legislation/Paperwork

ReductionActof1995/PRA-Listing.html. 

FOR FURTHER INFORMATION CONTACT: 

William Parham at (410) 786–4669. 

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 currently 

approved collection; Title of 

Information Collection: Medicaid Drug 

Rebate Program Labeler Reporting 

Format; Use: Labelers transmit drug 

product and pricing data to CMS within 

30 days after the end of each calendar 

month and quarter. CMS calculates the 

unit rebate amount (URA) and the unit 

rebate offset amount (UROA) for each 

new drug application (NDC) and 

distributes to all State Medicaid 

agencies. States use the URA to invoice 

the labeler for rebates and the UROA to 

report onto CMS–64. The monthly data 

is used to calculate Federal Upper Limit 

(FUL) prices for applicable drugs and 

for states that opt to use this data to 

establish their pharmacy reimbursement 

methodology. In this November 2021 

iteration, CMS–367d (Manufacturer 

Contact Form) is being revised to 

include a signature/date line for the 

submitter to confirm that the 

information provide is accurate, and we 

have additionally updated the entire 

367d to a fillable format, per multiple 

labeler requests. CMS–367e (Quarterly 

VBP–MBP Data) is a new form that is 

intended for manufacturers to use (as 

needed) on a quarterly basis, to transmit 

pricing data (best prices associated with 

value-based purchasing (VBP) 

arrangements) for each of their covered 

outpatient drugs (CODs) to CMS either 

via direct file upload to the MDP System 

or manual on-line entry. The CMS–367e 

form is optional. We are not proposing 

any changes to the CMS–367a 

(Quarterly Pricing), CMS–367b 

(Monthly Pricing), or CMS–367c 

(Product Data) forms. Form Number: 

CMS–367a, b, c, d, and e (OMB control 

number: 0938–0578); Frequency: 

Monthly, quarterly, and on occasion; 

Affected Public: Private sector (Business 

or other for-profits); Number of 

Respondents: 780; Total Annual 

Responses: 15,020; Total Annual Hours: 

564,394. (For policy questions regarding 

this collection contact Andrea 

Wellington at 410–786–3490.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Notice of 

Rescission of Coverage and Disclosure 

Requirements for Patient Protection 

under the Affordable Care Act; Use: 

Sections 2712 and 2719A of the Public 

Health Service Act (PHS Act), as added 

by the Affordable Care Act, contain 

rescission notice, and patient protection 

disclosure requirements that are subject 

to the Paperwork Reduction Act of 1995. 

The No Surprises Act, enacted as part of 


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Federal Register / Vol. 87, No. 43 / Friday, March 4, 2022 / Notices 12457 

the Consolidated Appropriations Act, 

2021, amended section 2719A of the 

PHS Act to sunset when the new 

emergency services protections under 

the No Surprises Act take effect. The 

provisions of section 2719A of the PHS 

Act will no longer apply with respect to 

plan years beginning on or after January 

1, 2022. The No Surprises Act recodified the patient protections related 

to choice of health care professional 

under section 2719A of the PHS Act in 

newly added section 9822 of the 

Internal Revenue Code, section 722 of 

the Employee Retirement Income 

Security Act, and section 2799A–7 of 

the PHS Act and extended the 

applicability of these provisions to 

grandfathered health plans for plan 

years beginning on or after January 1, 

2022. The rescission notice will be used 

by health plans to provide advance 

notice to certain individuals that their 

coverage may be rescinded as a result of 

fraud or intentional misrepresentation 

of material fact. The patient protection 

notification will be used by health plans 

to inform certain individuals of their 

right to choose a primary care provider 

or pediatrician and to use obstetrical/ 

gynecological services without prior 

authorization. The related provisions 

are finalized in the 2015 final 

regulations titled ‘‘Final Rules under the 

Affordable Care Act for Grandfathered 

Plans, Preexisting Condition Exclusions, 

Lifetime and Annual Limits, 

Rescissions, Dependent Coverage, 

Appeals, and Patient Protections’’ (80 

FR 72192, November 18, 2015) and 2021 

interim final regulations titled 

‘‘Requirements Related to Surprise 

Billing; Part I’’ (86 FR 36872, July 13, 

2021). The 2015 final regulations also 

require that, if State law prohibits 

balance billing, or a plan or issuer is 

contractually responsible for any 

amounts balanced billed by an out-ofnetwork emergency services provider, a 

plan or issuer must provide a 

participant, beneficiary or enrollee 

adequate and prominent notice of their 

lack of financial responsibility with 

respect to amounts balanced billed in 

order to prevent inadvertent payment by 

the individual. Plans and issuers will 

not be required to provide this notice for 

plan years beginning on or after January 

1, 2022. Form Number: CMS–10330 

(OMB control number: 0938–1094); 

Frequency: On Occasion; Affected 

Public: State, Local, or Tribal 

Governments, Private Sector; Number of 

Respondents: 2,277; Total Annual 

Responses: 15,752; Total Annual Hours: 

814. (For policy questions regarding this 

collection, contact Usree 

Bandyopadhyay at 410–786–6650.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Requirements 

Related to Surprise Billing: Qualifying 

Payment Amount, Notice and Consent, 

Disclosure on Patient Protections 

Against Balance Billing, and State Law 

Opt-in; Use: On December 27, 2020, the 

Consolidated Appropriations Act, 2021 

(Pub. L. 116–260), which included the 

No Surprises Act, was signed into law. 

The No Surprises Act provides federal 

protections against surprise billing and 

limits out-of-network cost sharing under 

many of the circumstances in which 

surprise medical bills arise most 

frequently. The 2021 interim final 

regulations ‘‘Requirements Related to 

Surprise Billing; Part I’’ (86 FR 36872, 

2021 interim final regulations) issued by 

the Departments of Health and Human 

Services, the Department of Labor, the 

Department of Treasury, and the Office 

of Personnel Management, implement 

provisions of the No Surprises Act that 

apply to group health plans, health 

insurance issuers offering group or 

individual health insurance coverage, 

and carriers in the Federal Employees 

Health Benefits (FEHB) Program that 

provide protections against balance 

billing and out-of-network cost sharing 

with respect to emergency services, nonemergency services furnished by 

nonparticipating providers at certain 

participating health care facilities, and 

air ambulance services furnished by 

nonparticipating providers of air 

ambulance services. The 2021 interim 

final regulations prohibit 

nonparticipating providers, emergency 

facilities, and providers of air 

ambulance services from balance billing 

participants, beneficiaries, and enrollees 

in certain situations unless they satisfy 

certain notice and consent 

requirements. The No Surprises Act and 

the 2021 interim final regulations 

require group health plans and issuers 

of health insurance coverage to provide 

information about qualifying payment 

amounts to nonparticipating providers 

and facilities and to provide disclosures 

on patient protections against balance 

billing to participants, beneficiaries and 

enrollees. Self-insured plans opting in 

to a specified state law are required to 

provide a disclosure to participants. 

Certain nonparticipating providers and 

nonparticipating emergency facilities 

may provide participants, beneficiaries, 

and enrollees with notice and obtain 

their consent to waive balance billing 

protections, provided certain 

requirements are met. In addition, 

certain providers and facilities are 

required to provide disclosures on 

patient protections against balance 

billing to participants, beneficiaries and 

enrollees. Form Number: CMS–10780 

(OMB control number: 0938–1401); 

Frequency: On Occasion; Affected 

Public: Individuals, State, Local, or 

Tribal Governments, Private Sector; 

Number of Respondents: 2,494,683; 

Total Annual Responses: 58,696,352; 

Total Annual Hours: 4,933,110. (For 

policy questions regarding this 

collection, contact Usree 

Bandyopadhyay at 410–786–6650.) 

4. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare 

Program; Prior Authorization Process for 

Certain Durable Medical Equipment, 

Prosthetic, Orthotics, and Supplies 

(DMEPOS); Use: Section 1834(a)(15) of 

the Social Security Act (the Act) 

authorizes the Secretary to develop and 

periodically update a list of DMEPOS 

that the Secretary determines, on the 

basis of prior payment experience, are 

frequently subject to unnecessary 

utilization and to develop a prior 

authorization process for these items. 

Pursuant to this authority, CMS 

published final rules CMS–6050–F and 

CMS–1713–F. 

The information required under this 

collection is used to determine proper 

payment and coverage for DMEPOS 

items. The information requested 

includes all documents and information 

that demonstrate the DMEPOS item 

requested is reasonable and necessary 

for the beneficiary and meets applicable 

Medicare requirements. The 

documentation will be reviewed by 

trained registered nurses, therapists, or 

physician reviewers to determine if 

item(s) or service requested meets all 

applicable Medicare coverage, coding 

and payment rules. Form Number: 

CMS–10524 (OMB control number: 

0938–1293); Frequency: Occasionally; 

Affected Public: Private Sector (Business 

or other for-profits, Not-for-Profit 

Institutions); Number of Respondents: 

273,305; Total Annual Responses: 

273,305; Total Annual Hours: 136,652. 

(For policy questions regarding this 

collection contact Stephanie Collins at 

(410) 786–0959.) 

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Fiscal 

Soundness Reporting Requirements 

(FSRR); Use: Title 18 Section 

1857(d)(4)(A)(i) requires that contracting 

organizations such as Medicare Health 

Plans (including Medicare Advantage 

(MA) organizations, Medicare-Medicaid 

Capitated Financial Alignment 

Demonstrations (MMPs)) and 1876 Cost 


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12458 Federal Register / Vol. 87, No. 43 / Friday, March 4, 2022 / Notices 

Plans), Prescription Drug Plan sponsors 

(PDPs), and Programs of All-Inclusive 

Care for the Elderly (PACE) 

organizations report financial 

information demonstrating the 

organization has a fiscally sound 

operation. The FSRR is designed to 

capture financial data of these 

contracting entities. The Division of 

Finance and Benefits (DFB) within the 

Medicare Advantage Contract 

Administration Group (MCAG) of CMS 

is assigned the responsibility of 

reviewing ongoing financial 

performance of the contracting entities. 

All contracting organizations must 

submit audited annual financial 

statements one time per year. In 

addition to the audited annual 

submission, Health Plans with a 

negative net worth and/or a net loss and 

the amount of that loss is greater than 

one-half of the organization’s total net 

worth submit quarterly financial 

statements for fiscal soundness 

monitoring. Part D organizations are 

required to submit three (3) quarterly 

financial statements. Lastly, PACE 

organizations are required to file four (4) 

quarterly financial statements for the 

first three (3) years in the program. After 

the first three (3) years, PACE 

organizations with a negative net worth 

and/or a net loss and the amount of that 

loss is greater than one-half of the 

organization’s total net worth must 

submit quarterly financial statements for 

fiscal soundness monitoring. Form 

Number: CMS–906 (OMB control 

number: 0938–0496); Frequency: 

Quarterly and Yearly; Affected Public: 

Private Sector (Business or other forprofits, Not-for-Profit Institutions); 

Number of Respondents: 936; Total 

Annual Responses: 1,958; Total Annual 

Hours: 652. (For policy questions 

regarding this collection contact Christa 

M. Zalewski at (410) 786–1971.) 

Dated: March 1, 2022. 

William N. Parham, III, 

Director, Paperwork Reduction Staff, Office 

of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2022–04644 Filed 3–3–22; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10108] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services, Health and Human 

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 

the necessity and utility of the proposed 

information collection for the proper 

performance of the agency’s functions, 

the accuracy of the estimated burden, 

ways to enhance the quality, utility, and 

clarity of the information to be 

collected, and the use of automated 

collection techniques or other forms of 

information technology to minimize the 

information collection burden. 

DATES: Comments must be received by 

May 3, 2022. 

ADDRESSES: When commenting, please 

reference the document identifier or 

OMB control number. 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: ll, 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’ website address at 

website address at https://www.cms.gov/ 

Regulations-and-Guidance/Legislation/ 

PaperworkReductionActof1995/PRAListing. 

FOR FURTHER INFORMATION CONTACT: 

William N. Parham at (410) 786–4669. 

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–10108 Medicaid Managed Care 

Regulations 

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 

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: Revision of a currently 

approved collection; Title of 

Information Collection: Medicaid 

Managed Care Regulations; Use: 

Information collected includes 

information about managed care 

programs, grievances and appeals, 

enrollment broker contracts, and 

managed care organizational capacity to 

provide health care services. Medicaid 

enrollees use the information collected 

and reported to make informed choices 

regarding health care, including how to 

access health care services and the 

grievance and appeal system. States use 

the information collected and reported 

as part of its contracting process with 

managed care entities, as well as its 

compliance oversight role. We use the 


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