(CMS-10611) Medicare Outpatient Observation Notice (MOON)

ICR 201612-0938-010

OMB: 0938-1308

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2016-12-02
Supplementary Document
2016-12-02
Supplementary Document
2016-08-03
Supporting Statement A
2016-08-03
IC Document Collections
IC ID
Document
Title
Status
221292 Modified
ICR Details
0938-1308 201612-0938-010
Historical Active 201608-0938-001
HHS/CMS
(CMS-10611) Medicare Outpatient Observation Notice (MOON)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/07/2016
Retrieve Notice of Action (NOA) 12/07/2016
  Inventory as of this Action Requested Previously Approved
12/31/2019 36 Months From Approved
1,399,999 0 0
350,000 0 0
0 0 0

The Centers for Medicare & Medicaid Services (CMS) requests a new collection named the Medicare Outpatient Observation Notice (MOON), Form CMS-10611, as the written notice promulgated by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) Public Law 114-42 enacted by Congress on August 6, 2015 and effective 12 months after the date of the enactment which is August 6, 2016. The NOTICE Act amended Section 1866(a)(1) of the Social Security Act (the Act) (42 U.S.C. 1395cc(a)(1)) by adding subparagraph (Y) which sets forth requirements for Medicare participating hospitals and critical access hospitals (CAHs) to provide outpatient notification to persons entitled to Medicare benefits under Title XVIII of Act, who are hospital observation patients for more than 24 hours. Notification must be given no later than 36 hours after the initiation of observation services. This notification process consists of a written notice as determined by the Secretary, which will be the MOON, and an oral explanation of the written notice. The notice must include the reason the individual is receiving observation services and must explain the implications of receiving outpatient observation services, such as cost sharing, and post-hospitalization eligibility for Medicare coverage of skilled nursing facility (SNF) services. The MOON is a standardized notice written in plain language that includes all of the informational elements required by statute.

US Code: 42 USC 1395c(a)(1) Name of Law: Social Security Act
  
None

0938-AS77 Final or interim final rulemaking 81 FR 56762 08/22/2016

Yes

1
IC Title Form No. Form Name
Medicare Outpatient Observation Notice CMS-10611 MOON Form

  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 1,399,999 0 0 1,399,999 0 0
Annual Time Burden (Hours) 350,000 0 0 350,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
We inadvertently did not include outpatient observation service claims for Medicare Advantage (MA) enrollees in the estimated MOON burden in the proposed rule. We have updated our calculations to include MA outpatient observation service claims and our estimate now fully accounts for outpatient services claims for all Medicare Beneficiaries. In addition, we have increased the estimated time for hospitals to prepare and deliver the MOON to 15 minutes. We have done this to account for the addition of a free text field to indicate why a beneficiary is receiving outpatient observation services, in response to public comments suggesting such rationale be included in the MOON.

$0
No
No
No
No
No
Uncollected
Denise King 410 786-1013 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/08/2016


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