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Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202310-0938-001 · OMB 0938-0512 · Received in OIRA

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Supplementary Document
2023-10-18
Supporting Statement A
2023-10-18
IC Document Collections
IC ID
Document
Title
Status
8133 Modified
ICR Details
0938-0512 202310-0938-001
Received in OIRA 201910-0938-006
HHS/CMS CCSQ
Organ Procurement Organization's Health Insurance Benefits Agreement and Supporting Regulations 42 CFR 486.301-486.348 (CMS-576 and CMS-576A)
Reinstatement with change of a previously approved collection   No
Regular 10/18/2023
  Requested Previously Approved
36 Months From Approved
16 0
32 0
0 0
Organizations seeking designation from CMS as a qualified and approved Organ Procurement Organization (OPO), as per §§ 371(a) and 1138 of the Social Security Act (“the Act”) must complete and submit the CMS-576 form, titled “Organ Procurement Organization (OPO) Request for Designation As An OPO Under § 1138 Of The Social Security Act.” After designation as an OPO, the organization must sign a “Health Insurance Benefits Agreement” (CMS-576A form) in order to be reimbursed by Medicare for their services.
Statute at Large: 19 Stat. 372
   Statute at Large: 18 Stat. 1138
  
None
Not associated with rulemaking
  88 FR 38513 06/13/2023
88 FR 71570 10/17/2023
No
  Total Request 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 16 0 0 -42 0 58
Annual Time Burden (Hours) 32 0 0 3 0 29
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The time burden for the CMS-576A form has been reduced. The previous PRA package estimated the number of respondents for the CMS-576A form to be 58. It was further estimated that it would take 30 minutes to complete the CMS- 576A form and the total annual time burden across all respondents was estimated to be 29 hours. In the current PRA package, we estimate that for the CMS-576A form, there are 56 respondents every 4 years or 15 respondents annually. We have further estimated that it would take 30 minutes to complete each CMS-576A form and 7.5 hours annually to complete all CMS-576A forms across all 15 respondents. We also estimate that the cost burden for completion of each CMS-576A form would be $58 and the total annual cost burden across all respondents would be $864. Also, in the current PRA package, we estimate that for the CMS-576 form, there would be 1 respondent annually for OPOs that are undergoing a CHOW, merger or consolidation. We estimate that it would take approximately 24 hours to complete the CMS-576 form and that the total annual time burden across all respondents would also be 24 hours. We estimate that the cost burden for each CMS-576 form would be $2,765 and the total annual cost burden across all respondents would also be $2,765.
$447
No
    No
    No
No
No
No
No
Denise King 410 786-1013 Denise.King@cms.hhs.gov
  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.
10/18/2023