Federal Register / Vol. 84, No. 230 / Friday, November 29, 2019 / Notices 65817

other company, in a nonbanking activity (PRA), federal agencies are required to 3506(c)(2)(A) of the PRA (44 U.S.C. that is listed in § 225.28 of Regulation Y publish notice in the Federal Register 3506(c)(2)(A)) requires federal agencies (12 CFR 225.28) or that the Board has concerning each proposed collection of to publish a 30-day notice in the determined by Order to be closely information, including each proposed Federal Register concerning each related to banking and permissible for extension or reinstatement of an existing proposed collection of information, bank holding companies. Unless collection of information, and to allow including each proposed extension or otherwise noted, these activities will be a second opportunity for public reinstatement of an existing collection conducted throughout the United States. comment on the notice. Interested of information, before submitting the Each notice is available for inspection persons are invited to send comments collection to OMB for approval. To at the Federal Reserve Bank indicated. regarding the burden estimate or any comply with this requirement, CMS is The notice also will be available for other aspect of this collection of publishing this notice that summarizes inspection at the offices of the Board of information, including the necessity and the following proposed collection(s) of Governors. Interested persons may utility of the proposed information information for public comment: express their views in writing on the collection for the proper performance of 1. Type of Information Collection question whether the proposal complies the agency’s functions, the accuracy of Request: Extension without change of a with the standards of section 4 of the the estimated burden, ways to enhance currently approved collection; Title of BHC Act. the quality, utility, and clarity of the Information Collection: Health Unless otherwise noted, comments information to be collected, and the use Insurance Common Claims Form and regarding the applications must be of automated collection techniques or Supporting Regulations at 42 CFR part received at the Reserve Bank indicated other forms of information technology to 424, subpart C (CMS–1500 and CMS– or the offices of the Board of Governors, minimize the information collection 1490S); Use: Social Security ACT, Part Ann E. Misback, Secretary of the Board, burden. E, Section 1861(s) provides definition of services and institutions covered under 20th Street and Constitution Avenue DATES: Comments on the collection(s) of the Act. The CMS–1500 is used to bill NW, Washington, DC 20551–0001, not information must be received by the for services covered under section later than December 12, 2019. OMB desk officer by December 30, 2019. A. Federal Reserve Bank of St. Louis 1861(a)(1) by persons entitled to ADDRESSES: When commenting on the payment for such services. Benefits are (David L. Hubbard, Senior Manager) proposed information collections, P.O. Box 442, St. Louis, Missouri paid either to the physician/supplier please reference the document identifier under an agreement, the beneficiary on 63166–2034. Comments can also be sent or OMB control number. To be assured electronically to the basis of an itemized bill per section consideration, comments and 1842(b)(3)(B)(i) and (ii) of the Social [email protected]: recommendations must be received by 1. First Waterloo Bancshares, Inc., Security Act, or to an organization the OMB desk officer via one of the authorized to receive payment per Waterloo, Illinois; to acquire Best following transmissions: OMB, Office of Hometown Bancorp, Inc., and thereby 1842(b)(6). Information and Regulatory Affairs, The CMS–1500 and the CMS–1490S indirectly acquire Best Hometown Bank, Attention: CMS Desk Officer, Fax forms are used to deliver information to both of Collinsville, Illinois, and thereby Number: (202) 395–5806 OR, Email: CMS in order for CMS to reimburse for operate a savings association pursuant [email protected]. provided services. Medicare to section 4(c)(8) of the BHC Act. To obtain copies of a supporting Administrative Contractors use the data Board of Governors of the Federal Reserve statement and any related forms for the collected on the CMS–1500 and the System, November 22, 2019. proposed collection(s) summarized in CMS–1490S to determine the proper Yao-Chin Chao, this notice, you may make your request amount of reimbursement for Part B Assistant Secretary of the Board. using one of following: medical and other health services (as [FR Doc. 2019–25817 Filed 11–27–19; 8:45 am] 1. Access CMS’ website address at listed in section 1861(s) of the Social website address at https://www.cms.gov/ BILLING CODE P Security Act) provided by physicians Regulations-and-Guidance/Legislation/ and suppliers to beneficiaries. The PaperworkReductionActof1995/PRA- CMS–1500 is submitted by physicians/ Listing.html. suppliers for all Part B Medicare. DEPARTMENT OF HEALTH AND 1. Email your request, including your HUMAN SERVICES Serving as a common claim form, the address, phone number, OMB number, CMS–1500 can be used by other third- Centers for Medicare & Medicaid and CMS document identifier, to party payers (commercial and nonprofit Services [email protected]. health insurers) and other Federal 2. Call the Reports Clearance Office at programs (e.g., TRICARE, RRB, and [Document Identifier CMS–1500/1490S, (410) 786–1326. Medicaid). As the CMS–1500 displays CMS–10704 and CMS–10338] FOR FURTHER INFORMATION CONTACT: data items required for other third-party William Parham at (410) 786–4669. Agency Information Collection payers in addition to Medicare, the form SUPPLEMENTARY INFORMATION: Activities: Submission for OMB Under the is considered too complex for use by Review; Comment Request Paperwork Reduction Act of 1995 (PRA) beneficiaries when they file their own (44 U.S.C. 3501–3520), federal agencies claims. Therefore, the CMS–1490S AGENCY: Centers for Medicare & must obtain approval from the Office of (Patient’s Request for Medical Payment) Medicaid Services, HHS. Management and Budget (OMB) for each was explicitly developed for easy use by ACTION: Notice. collection of information they conduct beneficiaries who file their own claims. or sponsor. The term ‘‘collection of The English and Spanish version CMS– SUMMARY: The Centers for Medicare & information’’ is defined in 44 U.S.C. 1490S form (version 01/18) can be Medicaid Services (CMS) is announcing 3502(3) and 5 CFR 1320.3(c) and obtained from a Medicare an opportunity for the public to includes agency requests or Administrative Contractor or online. comment on CMS’ intention to collect requirements that members of the public Form Number: CMS–1500/1490S (OMB information from the public. Under the submit reports, keep records, or provide control number: 0938–1197); Frequency: Paperwork Reduction Act of 1995 information to a third party. Section Yearly; Affected Public: State, Local, or

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Tribal Governments; Number of Responses: 273,492; Total Annual ACTION: Request for public comment. Respondents: 2,029,505; Total Annual Hours: 6,016. (For policy questions Responses: 1,033,839,906; Total Annual regarding this collection contact Usree SUMMARY: The Intergovernmental Hours: 18,847,500. (For policy questions Bandyopadhyay at 410–786–6650.) Reference Guide (IRG) is a centralized regarding this collection contact 3. Type of Information Collection and automated repository of state and Charlene Parks at 410–786–8684.) Request: Extension without change of a tribal profiles that contains high-level 2. Type of Information Collection currently approved collection; Title of descriptions of each state and tribal Request: Extension of a currently Information Collection: Affordable Care child support enforcement (CSE) approved collection; Title of Act Internal Claims and Appeals and program. These profiles provide state, Information Collection: Health External Review Procedures for Non- tribal, and foreign country CSE agencies Reimbursement Arrangements and grandfathered Group Health Plans and with an effective and efficient method Other Account-Based Group Health Issuers and Individual Market Issuers; for updating and accessing information Plans; Use: On June 20, 2019, the Use: The information collection needed to process intergovernmental Department of the Treasury, the requirements ensure that claimants child support cases. Department of Labor, and the receive adequate information regarding Department of Health and Human the plan’s claims procedures and the DATES: Comments due within 60 days of Services (collectively, the Departments) plan’s handling of specific benefit publication. In compliance with the issued final regulations titled ‘‘Health claims. Claimants need to understand requirements of Section 3506(c)(2)(A) of Reimbursement Arrangements and plan procedures and plan decisions in the Paperwork Reduction Act of 1995, Other Account-Based Group Health order to appropriately request benefits the Administration for Children and Plans’’ (84 FR 28888) under section and/or appeal benefit denials. The Families is soliciting public comment 2711 of the PHS Act and the health information collected in connection on the specific aspects of the nondiscrimination provisions of HIPAA, with the HHS-administered federal information collection described above. Public Law 104–191 (HIPAA external review process is collected by ADDRESSES: Copies of the proposed nondiscrimination provisions). The HHS, and is used to provide claimants regulations expand the use of health collection of information can be with an independent external review. obtained and comments may be reimbursement arrangements and other Form Number: CMS–10338 (OMB account-based group health plans forwarded by emailing infocollection@ control number: 0938–1099); Frequency: acf.hhs.gov. Alternatively, copies can (collectively referred to as HRAs). In Occasionally; Affected Public: State, general, the regulations expand the use also be obtained by writing to the Local, or Tribal Governments; Number Administration for Children and of HRAs by eliminating the current of Respondents: 109,653; Total Annual prohibition on integrating HRAs with Families, Office of Planning, Research Responses: 4,711; Total Annual Hours: and Evaluation, 330 C Street SW, individual health insurance coverage, 1,195,626. (For policy questions thereby permitting employers to offer Washington, DC 20201, Attn: ACF regarding this collection contact Laura Reports Clearance Officer. All requests, individual coverage HRAs to employees Byabazaire at 410–786–6650.) that can be integrated with individual emailed or written, should be identified health insurance coverage or Medicare. Dated: November 25, 2019. by the title of the information collection. William N. Parham, III, Under the regulations employees will be SUPPLEMENTARY INFORMATION: permitted to use amounts in an Director, Paperwork Reduction Staff, Office individual coverage HRA to pay of Strategic Operations and Regulatory Description: The Office of Child expenses for medical care (including Affairs. Support Enforcement (OCSE) is premiums for individual health [FR Doc. 2019–25861 Filed 11–27–19; 8:45 am] proposing to add a new section (Section O) with six questions pertaining to insurance coverage and Medicare), BILLING CODE 4120–01–P subject to certain requirements. This family violence in the state profile. This information collection includes will help process intergovernmental provisions related to substantiation of DEPARTMENT OF HEALTH AND cases with family violence and help individual health insurance coverage HUMAN SERVICES ensure the safety of children and (45 CFR 146.123(c)(5)), the notice families. OCSE is also proposing to requirement for individual coverage Administration for Children and delete Sections A–L (140 questions) HRAs (45 CFR 146.123(c)(6)), and Families from the tribal profile and create new sections (Sections A–D) with 11 notification of termination of coverage Proposed Information Collection (45 CFR 146.123(c)(1)(iii)). Form questions regarding case processing. Activity; Intergovernmental Reference This will assist in the efficient Number: CMS–10704 (OMB Control Guide (IRG) OMB #0970–0209 Number 0938–1361); Frequency: processing of paternity and support Annually; Affected Public: Private AGENCY: Office of Child Support obligations. Sector, State Governments; Number of Enforcement, Administration for Respondents: State and tribal CSE Respondents: 2,005; Total Annual Children and Families, HHS. agencies.

ANNUAL BURDEN ESTIMATES

Total Number of Average Information collection number of responses per burden hour Annual instrument respondents respondent per response burden hours

IRG: State Profile Guidance (states and territories) ...... 54 18 0.3 292 IRG: Tribal Profile Guidance ...... 62 18 0.3 335

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