[Federal Register: December 10, 2004 (Volume 69, Number 237)]
[Notices]
[Page 71816-71817]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr10de04-72]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services
[Document Identifier: CMS-10115, CMS-10123 & 10124, CMS-R-211, CMS-
2552, and CMS-10048]
Agency Information Collection Activities: Proposed Collection;
Comment Request.
AGENCY: Centers for Medicare and Medicaid Services.
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid
Services (CMS) (formerly known as the Health Care Financing
Administration (HCFA)), Department of Health and Human Services, is
publishing the following summary of proposed collections for public
comment. Interested persons are invited to send comments regarding this
burden estimate or any other aspect of this collection of information,
including any of the following subjects: (1) The necessity and utility
of the proposed information collection for the proper performance of
the agency's functions; (2) the accuracy of the estimated burden; (3)
ways to enhance the quality, utility, and clarity of the information to
be collected; and (4) the use of automated collection techniques or
other forms of information technology to minimize the information
collection burden.
1. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Federal Funding
of Emergency Health Services (Section 1011): Enrollment Application;
Use: These information collections will allow hospitals and other
providers to enroll to receive payment for Section 1011 claim
submissions. Section 1011 provides $250 million per year for fiscal
years 2005-2008 for payments to eligible providers for emergency health
services provided to undocumented aliens and other specified aliens;
Form Number: CMS-10115 (OMB: 0938-0929); Frequency: Other: as
needed; Affected Public: Business or other for-profit, Not-for-profit
institutions, and State, Local or Tribal Govt.; Number of Respondents:
62,500; Total Annual Responses: 62,500; Total Annual Hours: 31,250.
2. Type of Information Collection Request: New Collection; Title of
Information Collection: Expedited Review Notices and Supporting
Regulations contained in 42 CFR Sections 405.1200 and 405.1202; Use:
These notices are used to inform beneficiaries that their provider
services will end, and to provide beneficiaries who request an
expedited determination with detailed information of why the services
should end; Form Numbers: CMS-10123 & 10124 (OMB: 0938-NEW);
Frequency: On occasion; Affected Public: Individuals or Households,
Business or other for-profit, and Not-for-profit institutions; Number
of Respondents: 4,200,000; Total Annual Responses: 4,200,000; Total
Annual Hours: 379,400.
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Model Application
Template for State Child Health Plan Under Title XXI of the Social
Security Act, State Children's Health Insurance Program, and Model
Application Template and Instructions; Use: States are required to
submit Title XXI plans and amendments for approval by the Secretary
pursuant to section 2102 of the Social Security Act in order to receive
funds for initiating and expanding health insurance coverage for
uninsured children. The model application template is used to assist
States in submitting a State Child Health Plan and amendments to that
plan; Form Number: CMS-R-211 (OMB: 0938-0707); Frequency:
Quarterly and Annually; Affected Public: State, Local or Tribal Govt.;
Number of Respondents: 40; Total Annual Responses: 40; Total Annual
Hours: 3,200.
4. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Hospital and
Health Care Complexes Cost Report and Supporting Regulations in 42 CFR
413.20 and 413.24; Use: This form is completed by Hospitals and Health
Care Complexes participating in the Medicare program. Hospitals and
Health Care Complexes use this form to report the health care costs for
services they provide. The information reported on this form is used by
CMS to determine the amount of reimbursable costs for services rendered
to Medicare beneficiaries. The revisions to this form contain the
provisions for implementing section 422 of the MMA. Section 422 deals
with the calculation of GME and IME payments for redistribution of
[[Page 71817]]
unused resident slots; Form Number: CMS-2552-96 (OMB 0938-
0050); Frequency: Annually; Affected Public: Business or other for-
profit, Not-for-profit institutions, and State, Local or Tribal
Government; Number of Respondents: 6,111; Total Annual Responses:
6,111; Total Annual Hours: 4,046,782.
5. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Application
Template for Health Insurance Flexibility and Accountability (HIFA)
Section Demonstration Proposal; Use: The HIFA Initiative affords states
an opportunity to expand coverage to the uninsured under Social
Security Act Section 1115 demonstrations authority. States will be able
to use Medicaid and State Child Health Insurance Program funds in
concert with private insurance options to expand coverage to low-income
uninsured individuals with a focus on those with income at or below 200
percent of the Federal poverty level. The model demonstration
application will facilitate State efforts in designing programs to
cover the uninsured; Form Number: CMS-10048 (OMB 0938-0848);
Frequency: Other: renewal every 5 yrs.; Affected Public: State, Local
or Tribal Government; Number of Respondents: 10; Total Annual
Responses: 9; Total Annual Hours: 42.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS'
Web Site address at http://www.cms.hhs.gov/regulations/pra/, or E-mail
your request, including your address, phone number, OMB number, and CMS
document identifier, to Paperwork@cms.hhs.gov, or call the Reports
Clearance Office on (410) 786-1326.
Written comments and recommendations for the proposed information
collections must be mailed within 60 days of this notice directly to
the CMS Paperwork Reduction Act Reports Clearance Officer designated at
the address below: CMS, Office of Strategic Operations and Regulatory
Affairs, Division of Regulations Development, Attention: Melissa
Musotto, Room C5-14-03, 7500 Security Boulevard, Baltimore, Maryland
21244-1850.
Dated: December 3, 2004.
John P. Burke, III,
CMS Paperwork Reduction Act Reports Clearance Officer, Office of
Strategic Operations and Regulatory Affairs, Regulations Development
Group.
[FR Doc. 04-27145 Filed 12-9-04; 8:45 am]
BILLING CODE 4120-03-P