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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services

          - [Document Identifier: CMS-21 and -21B, CMS-37, CMS-64, CMS-10098, CMS-10106, CMS-10120, CMS-10292, and CMS-10220]

# 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), 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 function; (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:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     CMS-21 (Quarterly Children's Health Insurance Program (CHIP) Statement of Expenditures for the Title XXI Program) and CMS-21B (State Children's Health Insurance Program Budget Report for the Title XXI Program State Plan Expenditures);                     *Use:*                     Forms CMS-21 and -21B provide CMS with the information necessary to issue quarterly grant awards, monitor current year expenditure levels, determine the allowability of State claims for reimbursement, develop CHIP financial management information, provide for State reporting of waiver expenditures, and ensure that the Federally                           ( print page 9580)                        established allotment is not exceeded. Further, these forms are necessary in the redistribution and reallocation of unspent funds over the Federally mandated timeframes;                     *Form Numbers:*                     CMS-21 and CMS-21B (OMB#: 0938-0731);                     *Frequency:*                     Quarterly;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     56;                     *Total Annual Responses:*                     448;                     *Total Annual Hours:*                     7,840. (For policy questions regarding this collection contact Jonas Eberly at 410-786-6232. For all other issues call 410-786-1326.)                

                    2.                     *Type of Information Collection Request:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     Medicaid Program Budget Report;                     *Use:*                     Form CMS-37 is prepared and submitted to the Centers for Medicare & Medicaid Services (CMS) by State Medicaid agencies. Form CMS-37 is the primary document used by CMS in developing the national Medicaid budget estimates that are submitted to the Office of Management and Budget and the Congress;                     *Form Number:*                     CMS-37 (OMB#: 0938-0101);                     *Frequency:*                     Quarterly;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     56;                     *Total Annual Responses:*                     224;                     *Total Annual Hours:*                     7,616. (For policy questions regarding this collection contact Jonas Eberly at 410-786-6232. For all other issues call 410-786-1326.)                

                    3.                     *Type of Information Collection Request:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program;                     *Use:*                     Form CMS-64 has been used since January 1980 by the Medicaid State Agencies to report their actual program benefit costs and administrative expenses to CMS. CMS uses this information to compute the Federal financial participation for the State's Medicaid Program costs. Certain schedules of the CMS-64 form are used by States to report budget, expenditure and related statistical information required for implementation of the Medicaid portion of the State Children's Health Insurance Programs;                     *Form Number:*                     CMS-64 (OMB#: 0938-0067);                     *Frequency:*                     Quarterly;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     56;                     *Total Annual Responses:*                     224;                     *Total Annual Hours:*                     16,464. (For policy questions regarding this collection contact Jonas Eberly at 410-786-6232. For all other issues call 410-786-1326.)                

                    4.                     *Type of Information Collection Request:*                     Reinstatement with change of a previously approved collection;                     *Title of Information Collection:*                     Beneficiary Satisfaction Survey;                     *Use:*                     The Beneficiary Satisfaction survey is performed to insure that the CMS 1-800-MEDICARE Helpline contractor is delivering satisfactory service to the Medicare beneficiaries. It gathers data on several Helpline operations such as print fulfillment and Web sites tool hosted on                     *http://www.medicare.gov.*                     Respondents to the survey are Medicare beneficiaries that have contacted 1-800-MEDICARE for information on benefits and services. CMS is seeking approval for additional questions to be added to the original collection entitled 800-Medicare Beneficiary Satisfaction survey. The original set of questions was used when placing outbound calls to callers regarding the service they received when they called the 800 Medicare Helpline with a Medicare question. The new expanded collection will include multiple survey methods to measure customer satisfaction not only with the Beneficiary Contact Center's (BCC's) handling of issues via telephone, but also the service provided to beneficiaries when they write a letter regarding their Medicare issue or use the e-mail and/or Web chat services provided by the BCC. The use of Customer Satisfaction Surveys is critical to the CMS mission to provide service to beneficiaries that is convenient, accessible, accurate, courteous, professional and responsive to the needs of diverse groups.                     *Form Number:*                     CMS-10098 (OMB#: 0938-0919);                     *Frequency:*                     Weekly, Monthly, and Yearly;                     *Affected Public:*                     Individuals and Households;                     *Number of Respondents:*                     36,144;                     *Total Annual Responses:*                     36,144;                     *Total Annual Hours:*                     6,033. (For policy questions regarding this collection contact Mark Broccolino at 410-786-6128. For all other issues call 410-786-1326.)                

                    5.                     *Type of Information Collection Request:*                     Revision of currently approved collection;                     *Title of Information Collection:*                     Medicare Authorization to Disclose Personal Health Information;                     *Use:*                     Unless permitted or required by law, the Health Insurance Portability and Accountability Act (HIPAA) prohibits Medicare (a HIPAA covered entity) from disclosing an individual's protected health information without a valid authorization. In order to be valid, an authorization must include specified core elements and statements. Medicare will make available to Medicare beneficiaries a standard, valid authorization to enable beneficiaries to request the disclosure of their protected health information. This standard authorization will simplify the process of requesting information disclosure for beneficiaries and minimize the response time for Medicare. The completed authorization will allow Medicare to disclose an individual's personal health information to a third party at the individual's request.                     *Form Number:*                     CMS-10106 (OMB#: 0938-0930);                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     Individuals or households;                     *Number of Respondents:*                     1,004,000;                     *Total Annual Responses:*                     1,004,000;                     *Total Annual Hours:*                     251,000. (For policy questions regarding this collection contact Lindsay Dixon-Brown at 410-786-1178. For all other issues call 410-786-1326.)                

                    6.                     *Type of Information Collection Request:*                     Extension without change of a currently approved collection;                     *Title of Information Collection:*                     1932 State Plan Amendment Template;                     *Use:*                     Section 1932(a)(1)(A) of the Social Security Act (the Act) grants states the authority to enroll Medicaid beneficiaries on a mandatory basis into managed care entities managed care organization (MCOs) and primary care case managers (PCCMs). Under this authority, a State can amend its Medicaid State plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance. This template may be used by States to easily modify their State plans if they choose to implement the provisions of section 1932(a)(1)(A).                

                    The State Medicaid Agencies will complete the template. CMS will review the information to determine if the State has met all the requirements of section 1932(a)(1)(A) and 42 CFR 438.50. If the requirements are met, CMS will approve the amendment to the State's title XIX plan giving the State the authority to enroll Medicaid beneficiaries on a mandatory basis into managed care entities MCOs and PCCMs. For a State to receive Medicaid funding, there must be an approved title XIX State plan;                     *Form Number:*                     CMS-10120 (OMB#: 0938-0933);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     56;                     *Total Annual Responses:*                     10;                     *Total Annual Hours:*                     100. (For policy questions regarding this collection contact Camille Dobson at 410-786-7065. For all other issues call 410-786-1326.)                

                    7.                     *Type of Information Collection Request:*                     Revision of a currently approved collection;                     *Title of Information Collection:*                     State Medicaid Health Information Technology (HIT) Plan (SMHP) and Model Checklist: Health Information Technology (HIT) Planning-Advance Planning Document (HIT P-APD);                     *Use:*                     Section 4201 of                           ( print page 9581)                        Recovery Act establishes 100 percent Federal financial participation (FFP) as reimbursement to States for making incentive payments to providers for meaningful use of certified electronic health record technology and 90 percent FFP for administering these payments. Additionally, States are required to conduct oversight of this program and ensure no duplicate payments; thus, CMS is requiring States to submit information to CMS for prior approval before drawing down funding. These documents, if States choose to implement these flexibilities, will require a collection of information to effectuate these changes.                

                    The State Medicaid agencies will complete the templates. CMS will review the information to determine if the State has met all of the requirements of the Recovery Act provisions the States choose to implement. If the requirements are met, CMS will approve the amendments giving the State the authority to implement their Health Information Technology (HIT) strategy and implementation plans. For a State to receive Medicaid Title XIX funding, there must be an approved State Medicaid HIT Plan, Planning Advance Planning Document and Implementation Advance Planning Document;                     *Form Number:*                     CMS-10292 (OMB#: 0938-1088);                     *Frequency:*                     Yearly, Once, Occasionally;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     56;                     *Total Annual Responses:*                     56;                     *Total Annual Hours:*                     56. (For policy questions regarding this collection contact Sherry Armstead at 410-786-4342. For all other issues call 410-786-1326.)                

                    8.                     *Type of Information Collection Request:*                     Extension without change of a currently approved collection;                     *Title of Information Collection:*                     Provider Enrollment, Chain and Ownership System (PECOS) Security Consent Form;                     *Use:*                     The primary function of the Medicare enrollment application is to obtain information about the provider or supplier and whether the provider or supplier meets Federal and/or State qualifications to participate in the Medicare program. In addition, the Medicare enrollment application gathers information regarding the provider or supplier's practice location, the identity of the owners of the enrolling organization, and information necessary to establish the correct claims payment. In establishing a Web based application process, we allow providers and suppliers the ability to enroll in the Medicare program via the Internet. For these applicants, no security consent form is needed to enroll or make a change in their Medicare enrollment information. These applicants receive complete access to their own enrollments through Internet-based Provider Enrollment, Chain and Ownership System (PECOS).                

In order to allow a provider or supplier to delegate the Medicare credentialing process to another individual or organization, it is necessary to establish a Security Consent Form for those providers and suppliers who choose to have another individual or organization access their enrollment information and complete enrollments on their behalf. These users could consist of administrative staff, independent contractors, or credentialing departments and are represented as Employer Organizations. Employer Organizations and its members must request access to enrollment data through a Security Consent Form. The security consent form replicates business service agreements between Medicare applicants and organizations providing enrollment services.

                    We are proposing two different versions of the Security Consent Form. The form, once signed, mailed and approved, grants an employer organization or its member's access to all current and future enrollment data for the Medicare provider.                     *Form Number:*                     CMS-10220 (OMB#: 0938-1035);                     *Frequency:*                     Occassionally;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     197,500;                     *Total Annual Responses:*                     197,500;                     *Total Annual Hours:*                     49,375. (For policy questions regarding this collection contact Alisha Banks at 410-786-0671. 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 address 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.                

To be assured consideration, comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on March 21, 2011.

                    OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax Number: (202) 395-6974,                     *E-mail: OIRA_submission@omb.eop.gov.*

Martique Jones,

Director, Regulations Development Group, Division B, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2011-3748 Filed 2-17-11; 8:45 am]

BILLING CODE 4120-01-P