(CMS-R-10) Advanced Directives (Medicare and Medicard)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS R-10 Response to Public Comments.docx	Supplementary Document	Uploaded 2017-02-27	Available
CMS-R-10 AdvancedDirectives FINAL 8-28-17.docx	Supporting Statement A	Uploaded 2017-08-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
189100	CMS-R-10 Form 83 - Part II (Policies and Procedures)		Removed
189099	CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)		Modified
189098	CMS-R-10 Form 83 - Part II (Developing Advanced Directive)		Removed
189097	CMS-R-10 Form 83 - Part II (Annual Update)		Modified

ICR Details

OMB Control No: 0938-0610	ICR Reference No: 201702-0938-011
Status: Historical Active	Previous ICR Reference No: 201312-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: 21020
Title: (CMS-R-10) Advanced Directives (Medicare and Medicard)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/25/2017
	Date Received in OIRA: 02/27/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	09/30/2017
Responses	55,039,479	0	55,044,127
Time Burden (Hours)	2,822,749	0	2,836,441
Cost Burden (Dollars)	0	0	0

---

Abstract: Certain Medicare and Medicaid organizations are responsible for collecting and documenting in a prominent place in medical records whether an individual has executed an advanced directive. This document indicates the individual's preference if he/she is incapacitated.

---

Authorizing Statute(s): PL: Pub.L. 105 - 33 4001 Name of Law: Establishment of Medicare+Choice program.
   PL: Pub.L. 101 - 508 4751 Name of Law: Omnibus Reconciliation Act of 1990
   PL: Pub.L. 105 - 33 4641 Name of Law: Placement of advance directive in medical record.
   PL: Pub.L. 105 - 33 4002 Name of Law: Transitional rules for current medicare HMO program.
   PL: Pub.L. 101 - 508 4206 Name of Law: Omnibus Reconciliation Act of 1990
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 89104	12/09/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 11037	02/17/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)
CMS-R-10 Form 83 - Part II (Annual Update)
CMS-R-10 Form 83 - Part II (Developing Advanced Directive)
CMS-R-10 Form 83 - Part II (Policies and Procedures)

---

ICR Summary of Burden

table that charts list 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	55,039,479	55,044,127	0	-96	-4,552	0
Annual Time Burden (Hours)	2,822,749	2,836,441	0	-6,864	-6,828	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Changes to the burden estimates are due to the decrease in the number of participating providers and organizations as a whole.

---

Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  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:

(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: 02/27/2017

---