[Federal Register: May 15, 2009 (Volume 74, Number 93)]
[Notices]
[Page 22932-22933]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr15my09-74]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: CMS-276, CMS-43, CMS-1763, CMS-R-194, CMS-R-232,
and CMS-R-296]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Centers for Medicare & Medicaid Services, HHS.
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Centers for Medicare & Medicaid
Services (CMS) 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: Prepaid Health
Plan Cost Report; Use: Health Maintenance Organizations and Competitive
Medical Plans (HMO/CMPs) contracting with the Secretary under Section
1876 of the Social Security Act are required to submit a budget and
enrollment forecast, four quarterly reports and a final certified cost
report. Health Care Prepayment Plans (HCPPs) contracting with the
Secretary under Section 1833 of the Social Security Act are required to
submit a budget and enrollment forecast, mid-year report, and final
cost report. An HMO/CMP is a health care delivery system that furnishes
directly or arranges for the delivery of the full spectrum of health
services to an enrolled population. A HCPP is a health care delivery
system that furnishes directly or arranges for the delivery of certain
physician and diagnostics services up to the full spectrum of non-
provider Part B health services to an enrolled population. These
reports will be used to establish the reasonable cost of delivering
covered services furnished to Medicare enrollees by an HMO/CMP or
HCPP.; Form Numbers: CMS-276 (OMB : 0938-0165); Frequency:
Recordkeeping, Reporting--Quarterly and Annually; Affected Public:
Business or other for-profit; Number of Respondents: 35; Total Annual
Responses: 128; Total Annual Hours: 5,285. (For policy questions
regarding this collection contact Temeshia Johnson at 410-786-8692. For
all other issues call 410-786-1326.)
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Application for
Hospital Insurance Benefits for Individuals with End Stage Renal
Disease: Use: Effective July 1, 1973, individuals with End Stage Renal
Disease (ESRD) became entitled to Medicare. Because this entitlement
has a different set of requirements, the existing applications for
Medicare were not sufficient to capture the information needed to
determine Medicare entitlement under the ESRD provisions of the law.
The Application for Hospital Insurance Benefits for Individuals with
End Stage Renal Disease, was designed to capture all the information
needed to make a Medicare entitlement determination; Form Numbers: CMS-
43 (OMB : 0938-0800; Frequency: Reporting--Once; Affected
Public: Individuals or households; Number of Respondents: 60,000; Total
Annual Responses: 60,000; Total Annual Hours: 25989. (For policy
questions regarding this collection contact Naomi Rappaport at 410-786-
2175. For all other issues call 410-786-1326.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Request for
Termination of Premium Hospital and/or Supplementary Medical Insurance:
Use: The Social Security Act (the Act) allows a Medicare enrollee to
voluntarily terminate Supplementary Medical Insurance (Part B) and/or
the premium Hospital Insurance (premium--Part A) coverage by filing a
written request with CMS or the Social Security Administration (SSA).
The Act also stipulates when coverage will end based upon the date the
request was filed. Because Medicare is recognized as a valuable
protection against the high cost of medical and hospital bills, when an
individual wishes to voluntarily terminate Part B and/or premium Part
A, CMS and SSA requests the reason that an individual wishes to
terminate coverage to ensure that the individual understands the
ramifications of the decision. The Request for Termination of Premium
Hospital and/or
[[Page 22933]]
Supplementary Medical Insurance, provides a standardized form to
satisfy the requirements of law as well as allowing both agencies to
protect the individual from an inappropriate decision; Form Numbers:
CMS-1763 (OMB : 0938-0025; Frequency: Reporting--Once;
Affected Public: Individuals or households; Number of Respondents:
14,000; Total Annual Responses: 14,000; Total Annual Hours: 5,831. (For
policy questions regarding this collection contact Naomi Rappaport at
410-786-2175. For all other issues call 410-786-1326.)
4. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Medicare
Disproportionate Share Adjustment Procedures and Criteria and
Supporting Regulations in 42 CFR 412.106: Use: Section 1886(d)(5)(F) of
the Social Security Act established the Medicare disproportionate share
adjustment (DSH) for hospitals, which provides additional payment to
hospitals that serve a disproportionate share of the indigent patient
population. This payment is an add-on to the set amount per case CMS
pays to hospitals under the Medicare Inpatient Prospective Payment
System (IPPS).
Under current regulations at 42 CFR 412.106, in order to meet the
qualifying criteria for this additional DSH payment, a hospital must
prove that a disproportionate percentage of its patients are low income
using Supplemental Security Income (SSI) and Medicaid as proxies for
this determination. This percentage includes two computations: (1) the
``Medicare fraction'' or the ``SSI ratio'' which is the percent of
patient days for beneficiaries who are eligible for Medicare Part A and
SSI and (2) the ``Medicaid fraction'' which is the percent of patient
days for patients who are eligible for Medicaid but not Medicare. Once
a hospital qualifies for this DSH payment, CMS also determines a
hospital's payment adjustment; Form Numbers: CMS-R-194 (OMB :
0938-0691; Frequency: Reporting--Occasionally; Affected Public:
Business or other for-profit and Not-for-profit institutions; Number of
Respondents: 800; Total Annual Responses: 800; Total Annual Hours: 400.
(For policy questions regarding this collection contact JoAnn Cerne at
410-786-4530. For all other issues call 410-786-1326.)
5. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Medicare
Integrity Program Organizational Conflict of Interest Disclosure
Certificate and Supporting Regulations at 42 CFR 421.300-421.316; Use:
Section 1893(d)(1) of the Social Security Act requires CMS to establish
a process for identifying, evaluating, and resolving conflicts of
interest. CMS proposed a process in Section 421.310 to mandate
submission of pertinent information regarding conflicts of interest.
The entities providing the information will be organizations that have
been awarded, or seek award of, a Medicare Integrity Program contract.
CMS needs this information to assess whether contractors who perform,
or who seek to perform, Medicare Integrity Program functions, such as
medical review, fraud review or cost audits, have organizational
conflicts of interest and whether any conflicts have been resolved.
Form Number: CMS-R-232 (OMB : 0938-0723); Frequency:
Reporting--On occasion; Affected Public: Business or other for-profit;
Number of Respondents: 11; Total Annual Responses: 44; Total Annual
Hours: 2,200. (For policy questions regarding this collection contact
Joe Strazzire at 410-786-2775. For all other issues call 410-786-1326.)
6. Type of Information Collection Request: Revision of a currently
approved Collection; Title of Information Collection: Home Health
Advance Beneficiary Notice (HHABN); Use: Home health agencies (HHAs)
are required to provide written notice to Medicare beneficiaries under
various circumstances involving the initiation, reduction, or
termination of services. The vehicle used in these situations is the
Home Health Advance Beneficiary Notice (HHABN). The notice is designed
to ensure that beneficiaries receive complete and useful information
regarding potential financial liability or any changes made to their
plan of care (POC) to enable them to make informed consumer decisions.
The notice must provide clear and accurate information about the
specified services and, when applicable, the cost of services when
Medicare denial of payment is expected by the HHA. Form Number: CMS-R-
296 (OMB : 0938-0781); Frequency: Reporting--Hourly, Daily,
Weekly, Monthly, Yearly, Quarterly, Semi-annually, Biennially, Once and
Occasionally; Affected Public: Business or other for-profits and Not-
for-profit institutions; Number of Respondents: 9024; Total Annual
Responses: 12,349,787; Total Annual Hours: 1,028,737. (For policy
questions regarding this collection contact Evelyn Blaemire at 410-786-
1803. For all other issues call 410-786-1326.)
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS'
Web Site at http://www.cms.hhs.gov/PaperworkReductionActof1995, 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.
In commenting on the proposed information collections please
reference the document identifier or OMB control number. To be assured
consideration, comments and recommendations must be submitted in one of
the following ways by July 14, 2009:
1. Electronically. You may submit your comments electronically to
http://www.regulations.gov. Follow the instructions for ``Comment or
Submission'' or ``More Search Options'' to find the information
collection document(s) accepting comments.
2. By regular mail. You may mail written comments to the following
address: CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development, Attention: Document Identifier/OMB
Control Number (CMS-10283), Room C4-26-05, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Dated: May 7, 2009.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations
and Regulatory Affairs.
[FR Doc. E9-11422 Filed 5-14-09; 8:45 am]
BILLING CODE 4120-01-P