Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 (CMS-576A)

Forms and Documents

Document Name	Status
Form CMS-576A Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 Form and Instruction	Modified
CMS-576A Supporting Statement 07.2019 clean 12.23.19.doc Supporting Statement A	2020-01-02

IC Document Collections

IC ID	Document Title	Status
8133	Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0512	ICR Reference No: 201910-0938-006
Status: Active	Previous ICR Reference No: 201605-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 (CMS-576A)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/06/2020
	Date Received in OIRA: 10/29/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved	01/31/2020
Responses	58	0	58
Time Burden (Hours)	29	0	116
Cost Burden (Dollars)	0	0	0

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Abstract: The information provided on this form serves as a basis for continuing the agreements with CMS and the 58 OPOs for participation in the Medicare and Medicaid programs and for reimbursement of service.

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Authorizing Statute(s): Statute at Large: 19 Stat. 372 Name of Statute: null
   Statute at Large: 18 Stat. 1138 Name of Statute: null
  

Citations for New Statutory Requirements: None

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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:
	84 FR 34896	07/19/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 55968	10/18/2019
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
Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348	CMS-576A	Health Insurance Benefits Agreement

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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	58	58	0	0	0	0
Annual Time Burden (Hours)	29	116	0	0	-87	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: The burden hours have decreased from 116 to 29 because the completion time for the form decreased. The cost decreased from $4,640 to $3,454.

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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

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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: 10/29/2019

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