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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 Start Printed Page 31332information 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 September 5, 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-R-138 Medicare Geographic Classification Review Board Procedures and Criteria

CMS-18F5 Application for Hospital Insurance and Supporting Regulations

CMS-10651 CMS Tribal Long Term Services and Supports (LTSS) Program Survey

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: Medicare Geographic Classification Review Board Procedures and Criteria; Use: During the first few years of IPPS, hospitals were paid strictly based on their physical geographic location concerning the wage index (Metropolitan Statistical Areas (MSAs)) and the standardized amount (rural, other urban, or large urban). However, a growing number of hospitals became concerned that their payment rates were not providing accurate compensation. The hospitals argued that they were not competing with the hospitals in their own geographic area, but instead that they were competing with hospitals in neighboring geographic areas. At that point, Congress enacted Section 1886(d)(10) of the Act which enabled hospitals to apply to be considered part of neighboring geographic areas for payment purposes based on certain criteria. The application and decision process is administered by the MGCRB which is not a part of CMS so that CMS could not be accused of any untoward action. However, CMS needs to remain apprised of any potential payment changes. Hospitals are required to provide CMS with copy of any applications that they made to the MGCRB. CMS also developed the guidelines for the MGCRB that were the interim final issue of the Federal Register, and must ensure that the MGCRB properly applied the guidelines. This check and balance process also contributes to limiting the number of hospitals that ultimately need to appeal their MGCRB decisions to the CMS Administrator. Form Number: CMS-R-138 (OMB control number: 0938-0573); Frequency: Occasionally; Affected Public: Businesses or other for-profits and Not-for-profit institutions; Number of Respondents: 300; Total Annual Responses: 300; Total Annual Hours: 300. (For policy questions regarding this collection contact Noel Manlove at 410-786-5161.)

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Application for Hospital Insurance and Supporting Regulations; Use: Individuals who are already entitled to retirement or disability benefits under Social Security or Railroad Retirement Board (RRB) benefits are automatically entitled to premium-free Medicare Hospital Insurance (Part A) when they attain age 65 or reach the 25th month of disability benefit entitlement. These individuals do not file a separate application for Medicare Part A because their application for Social Security or RRB benefits is also an application for Part A. The form is for individuals who are not eligible for Social Security for RRB benefits, but may qualify for premium-free Medicare Part A based on certain requirements outlined in § 406.11 and 406.15 or for certain disabled individuals who may enroll in premium Medicare Part A based on certain requirements outlined in § 406.20. Individuals may also choose to enroll in Medicare Part B at the same time they apply for Medicare Part A. Form Number: CMS-18F5 (OMB control number: 0938-0251); Frequency: Once; Affected Public: Individuals or households; Number of Respondents: 51,000; Total Annual Responses: 51,000; Total Annual Hours: 29,580. (For policy questions regarding this collection contact Carla Patterson at 410-786-8911.)

3. Type of Information Collection Request: New collection (request for a new OMB control number); Title of Information Collection: CMS Tribal Long Term Services and Supports (LTSS) Program Survey; Use: The Survey will provide CMS with an inventory of LTSS programs for older adults or individuals with disabilities managed by American Indian and Alaska Native (AI/AN) tribes. Information on tribal LTSS programs has previously been gathered through publicly available data via online research. However, not all of the information, including program contact Start Printed Page 31333information and program focus, are regularly available online as tribal Web sites are not updated frequently. Therefore, the survey will enable the collection of the most accurate information possible.

The respondents include 424 LTSS programs run by AI/AN tribes. Once the survey has been conducted, CMS will feature the survey data, specifically a list of AI/AN managed LTSS programs, online on The dissemination of survey data on will allow tribal communities and the general public to access this important data. Documentation of these programs will support sharing of LTSS best practices and innovative models employed in Indian Country. CMS will use the survey data to generate further content on LTSS in Indian Country, including literature reviews and reports on best practices.

Form Number: CMS-10651 (OMB control number: 0938-TBD); Frequency: Yearly; Affected Public: State, Local, or Tribal Governments; Number of Respondents: 425; Total Annual Responses: 425; Total Annual Hours: 106. (For policy questions regarding this collection contact John Johns at 410-786-7253).

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Dated: June 29, 2017.

William N. Parham, III,

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

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[FR Doc. 2017-14109 Filed 7-5-17; 8:45 am]