Non-Sub Change Memo

To: Jamie Wilson

Office of Information and Regulatory Affairs (OIRA)

Office of Management and Budget (OMB)

From: William N. Parham III

Office of Strategic Operations and Regulatory Affairs (OSORA)

Centers for Medicare and Medicaid Services (CMS)

Date: November XX, 2025

Subject: Non-Substantive Change Request – Health Insurance Benefit Agreement (OMB No: 0938-0832; CMS-1561); Health Insurance Benefit Agreement-Rural Health Clinics (OMB No. 0938-0832; CMS-1561A)

This memo requests approval of a non-substantive change to two of the approved information collections titled Health Insurance Benefit Agreement (OMB No: 0938-0832; CMS-1561); Health Insurance Benefit Agreement-Rural Health Clinics (OMB No. 0938-0832; CMS-1561A).

Background

The Health Insurance Benefit Agreement (CMS-1561) and Health Insurance Benefit Agreement for Rural Health Clinics (RHCs) (CMS-1561A), commonly referred to as the Provider Agreement is completed when a respective provider or supplier initially enrolls and is approved for Medicare participation. Providers and RHCs applying to participate in the Medicare program are required to agree to provide services in accordance with Federal requirements. The respective applicants will be required to sign the completed form and provide operational information to CMS to ensure they continue to meet all Federal requirements following their approval. The form is signed when the applicant and CMS enter into agreement at the beginning of the applicant’s participation in Medicare. The agreement remains in force so long as it’s not terminated by either party; thus, the collection is made once only during the applicant’s participation in Medicare.

In recent review of the forms, CMS identified that the contact information under the CMS disclosure section is now obsolete. The listed email addresses for questions about the provider agreement are no longer in use. In accordance with initial Medicare-participation and enrollment requirements, the Medicare Administrative Contractor (MAC) and State Survey Agency or CMS Survey Operations Group (for RHCs) are the first line of contact for the provider (refer to CMS Provider Integrity Manual Chapter 10, the State Operations Manual, Chapter 2, Section 2003A - Assisting Applicant Providers and Suppliers and Admin Info Memo 24-22).

Overview of Requested Changes

The Division of Continuing and Acute Care Providers (DCACP) in the Center for Clinical Standards and Quality (CCSQ) Quality, Safety and Oversight Group (QSOG) is requesting to make the following non-substantive edits to the currently approved information collection request. Please see the attached redline document for a visual illustration of the non-substantive edits to forms CMS-1561 and CMS-1561A. The following changes have no impact on the currently approved burden for this information collection. No data elements have been added or removed.

• CMS-1561 Section labeled ****CMS Disclosure****: Removal of email address and replace with instructions to contact the respective Medicare Administrative Contractor (MAC) or State Survey Agency.

• CMS-1561A Section labeled ****CMS Disclosure****: Removal of email address and replace with instructions to contact the respective Medicare Administrative Contractor (MAC) or CMS Survey Operations Group Location.