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Agency Information Collection Activities: Proposed Collection; Comment Request

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Centers for Medicare & Medicaid Services, HHS.




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.


Comments must be received by June 13, 2017.


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 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​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing.html.

2. Email your request, including your address, phone number, OMB number, and CMS document identifier, to

3. Call the Reports Clearance Office at (410) 786-1326.

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William Parham at (410) 786-4669.

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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-1561/1561A Health Insurance Benefit Agreement

CMS-370 and CMS-377 ASC Forms for Medicare Program Certification

CMS-10488 Consumer Experience Survey Data Collection

CMS-10393 Beneficiary and Family Centered Data Collection

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: Extension of a currently approved collection; Title of Information Collection: Health Insurance Benefit Agreement; Use: Applicants to the Medicare program are required to agree to provide services in accordance with federal requirements. The CMS-1561/1561A is essential in that is allows us to ensure that applicants are in compliance with the requirements. Applicants will be required to sign the completed form and provide operational information to us to assure that they continue to meet the requirements after approval. Form Number: CMS-1561/1561A (OMB control number: 0938-0832); Frequency: Yearly; Affected Public: Private sector—(Business or other for-profits and Not-for-profit institutions); Number of Respondents: 2,400; Total Annual Responses: 2,400; Total Annual Hours: 400. (For policy questions regarding this collection contact Shonte Carter at 410-786-3532).

2. Type of Information Collection Request: Extension of a currently approved collection; Titles of Information Collection: ASC Forms for Medicare Program Certification; Use: The CMS-370 is used to establish eligibility for payment. This agreement, upon submission by the ambulatory surgical center (ASC) and acceptance for filing by the Secretary of Health & Human Services, shall be binding on both the ASC and the Secretary. The agreement may be terminated by either party in accordance with regulations. In the event of termination, payment will not be available for ASC services furnished on or after the effective date of termination.

The Request for Certification or Update of Certification Information in the Medicare Program Form (CMS-377) Start Printed Page 17998is used by State agencies who conduct certification surveys on CMS' behalf to maintain information on the facility's characteristics that facilitate conducting surveys, e.g., determining the size and the composition of the survey team on the basis of the number of ORs/procedure rooms and the types of surgical procedures performed in the ASC. Form Numbers: CMS-370 and CMS-377 (OMB control number: 0938-0266); Frequency: Occasionally; Affected Public: Private Sector—Business or other for-profit and Not-for-profit institutions; Number of Respondents: 5,694; Total Annual Responses: 1,898; Total Annual Hours: 627. (For policy questions regarding this collection contact Erin McCoy at 410-786-2337.)

3. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Consumer Experience Survey Data Collection; Use: Section 1311(c)(4) of the Affordable Care Act requires the Department of Health and Human Services (HHS) to develop an enrollee satisfaction survey system that assesses consumer experience with qualified health plans (QHPs) offered through an Exchange. It also requires public display of enrollee satisfaction information by the Exchange to allow individuals to easily compare enrollee satisfaction levels between comparable plans. HHS established the QHP Enrollee Experience Survey (QHP Enrollee Survey) to assess consumer experience with the QHPs offered through the Marketplaces. The survey include topics to assess consumer experience with the health care system such as communication skills of providers and ease of access to health care services. CMS developed the survey using the Consumer Assessment of Health Providers and Systems (CAHPS®) principles (​cahps/​about-cahps/​principles/​index.html) and established an application and approval process for survey vendors who want to participate in collecting QHP enrollee experience data.

The QHP Enrollee Survey, which is based on the CAHPS® Health Plan Survey, will be used to (1) help consumers choose among competing health plans, (2) provide actionable information that the QHPs can use to improve performance, (3) provide information that regulatory and accreditation organizations can use to regulate and accredit plans, and (4) provide a longitudinal database for consumer research. CMS completed two rounds of developmental testing including 2014 psychometric testing and 2015 beta testing of the QHP Enrollee Survey. The psychometric testing helped determine psychometric properties and provided an initial measure of performance for Marketplaces and QHPs to use for quality improvement. Based on psychometric test results, CMS further refined the questionnaire and sampling design to conduct the 2015 beta test of the QHP Enrollee Survey. CMS previously obtained clearance for the 2016 and 2017 administrations of the QHP Enrollee Survey.

At this time, CMS is requesting to renew approval for the information collection related to the QHP Enrollee Experience Survey in 2018-2020. These activities are necessary to ensure that CMS fulfills legislative mandates established by section 1311(c)(4) of the Affordable Care Act to develop an “enrollee satisfaction survey system” and provide such information on Marketplace Web sites. CMS is also seeking approval to remove eight survey questions beginning with the 2018 survey administration. With the removal of these eight questions, the revised total estimated annual burden hours of national implementation of the QHP Enrollee Survey is 22,523 hours with 90,015 responses. The revised total annualized burden over three years for this requested information collection is 67,569 hours and the total average annualized number of responses is 270,045 responses. Form Number: CMS-10488 (OMB Control Number: 0938-1221); Frequency: Annually; Affected Public: Public sector (Individuals and Households), Private sector (Business or other for-profits and Not-for-profit institutions); Number of Respondents: 90,015; Total Annual Responses: 90,015; Total Annual Hours: 22,523; (For policy questions regarding this collection contact Nidhi Singh-Shah at 301-492-5110.)

4. Type of Information Collection Request: Revision of a previously approved collection; Title of Information Collection: Beneficiary and Family Centered Data Collection; Use: The CMS Quality Improvement Organization (QIO) Program includes Beneficiary and Family Centered Care (BFCC) QIOs whose functions, as set forth in Section 1862(g) of the Social Security Act, are to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. To accomplish these goals, the QIOs review health care services funded under Medicare to determine whether those services are reasonable, medically necessary, furnished in the appropriate setting, and meet professionally recognized standards of quality. The QIOs also review health care services where the beneficiary or a representative has complained about the quality of those services or is appealing alleged premature discharge.

Under the current 11th QIO Statement of Work (SOW), two organizations are providing services as BFCC QIOs across all of the United States. The QIO evaluation criteria have been revised to reflect this national regionalization and it is important for CMS to understand the impact on beneficiaries from this reorganization. The information will be used to evaluate the success of each QIO in meeting its contractual requirements and to understand the experience of Medicare beneficiaries and/or their representative with QIO contract mandated work. Form Number: CMS-10393 (OMB Control number: 0938-1177); Frequency: Once; Affected Public: Individuals or households; Number of Respondents: 24,970; Number of Responses: 24,970; Total Annual Hours: 2,899. (For policy questions regarding this collection, contact David Russo at 617-565-1310.)

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Dated: April 11, 2017.

William N. Parham, III,

Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs.

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[FR Doc. 2017-07568 Filed 4-13-17; 8:45 am]