Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A)

Forms and Documents

Document Name	Status
Form CMS-1561 Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491 Form and Instruction	Modified
CMS-1561 - Supporting Statement A (NPRM version 6) CLEAN.docx Supporting Statement A	2019-08-21

IC Document Collections

IC ID	Document Title	Status
8630	Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0832	ICR Reference No: 201907-0938-006
Status: Historical Inactive	Previous ICR Reference No: 201707-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 10/07/2019
	Date Received in OIRA: 08/21/2019
Terms of Clearance: Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved	01/31/2021
Responses	2,454	0	2,454
Time Burden (Hours)	2,454	0	2,454
Cost Burden (Dollars)	0	0	0

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Abstract: Applicants to the Medicare program are required to agree to provide services in accordance with Federal requirements. The CMS-1561 and 1561A are essential for CMS to ensure that applicants are in compliance with the requirements. Applicants will be required to sign the completed form and provide operational information to CMS to assure that they continue to meet the requirements after approval.

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Authorizing Statute(s): PL: Pub.L. 115 - 271 1866(e)(3) Name of Law: SUPPORT Act
   US Code: 42 USC 489 Name of Law: Allowable Charges
   US Code: 42 USC 491 Name of Law: Certification of Certain Health Facilities
  

Citations for New Statutory Requirements: PL: Pub.L. 115 - 271 1866(e)(3) Name of Law: SUPPORT Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT72	Proposed rulemaking	84 FR 40482	08/14/2019

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 40482	08/14/2019
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491	CMS-1561, CMS-1561A	Health Insurance Benefits Agreement ,   Health Insurance Benefits Agreement for RHC

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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: The August 14, 2019 (84 FR 40495) rule (RIN 0938-AT72, CMS-1715-P) proposes to amend 42 CFR part 489 to include OTPs as a provider as required by section 1866(e)(3) of the Act. We are proposing that the requirements under part 489, which include limitation of charges to beneficiaries, would apply to OTPs. Specifically, we are proposing to add OTPs to the list of providers in section 489.2 and that the provider agreements apply to OTPs only to furnish OUD treatment services. In that regard OTPs would be required to complete Provider Agreement CMS-1561 or CMS-1561A.

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Annual Cost to Federal Government: $80,540

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

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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: 08/21/2019

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