Hospice Information for Medicare Part D Plans (CMS-10538)

Forms and Documents

Document Name	Status
Form CMS-10538 Hospice Information for Medicare Part D Plans Form and Instruction	New
Response to Comments [rev 01-23-2015 by OSORA PRA].docx Supplementary Document	2015-01-23
CMS-10538Crosswalkjan15.xlsx Supplementary Document	2015-01-23
CMS-10538 - Supporting Statement A [rev 01-23-2015 by OSORA PRA].docx Supporting Statement A	2015-01-23

IC Document Collections

IC ID	Document Title	Status
214736	Hospice Information for Medicare Part D Plans Form and Instruction	New

ICR Details

OMB Control No: 0938-1269	ICR Reference No: 201501-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Information for Medicare Part D Plans (CMS-10538)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/02/2015
	Date Received in OIRA: 01/26/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2018	36 Months From Approved
Responses	376,487	0	0
Time Burden (Hours)	31,374	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Act in section 1861(dd) and Federal regulations in 42 CFR §418.106 and § 418.202(f) require hospice programs to provide individuals under hospice care with drugs and biologicals related to the palliation and management of the terminal illness as defined in the hospice plan of care. Medicare payment is made to the hospice for each day an eligible beneficiary is under the hospice's care, regardless of the amount of services provided on any given day. Because hospice care is a Medicare Part A benefit, drugs provided by the hospice and covered under the Medicare payment to the hospice program are not covered under Part D. The industry in conjunction with the National Council for Prescription Drug Programs, (NCPDP) developed a draft Medicare Part D Hospice Form to collect information necessary for the Part D sponsor to override a hospice prior authorization reject for beneficiaries enrolled in hospice. CMS made minor revisions to the NCPDP form to create this Standardized Form entitled Hospice Information for Medicare Part D Plans. This PRA submission is a request for approval of the standardized form available for use by Part D sponsors.

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Authorizing Statute(s): PL: Pub.L. 97 - 248 122 Name of Law: TEFRA
  

Citations for New Statutory Requirements: PL: Pub.L. 97 - 248 122 Name of Law: TEFRA

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 59772	10/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 3603	01/23/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Hospice Information for Medicare Part D Plans	CMS-10538	Hospice Information for Medicare Part D Plans

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	376,487	0	376,487	0	0	0
Annual Time Burden (Hours)	31,374	0	31,374	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Not applicable; this is a new collection.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/26/2015

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