Federal Register / Vol. 76, No. 34 / Friday, February 18, 2011 / Notices 9579 

Place: DoubleTree Hotel Atlanta 

Buckhead, 3342 Peachtree Road, NE., 

Piedmont Room, Atlanta, Georgia 

30326. 

Contact Person for Additional 

Information: Nancy Anderson, Chief, 

Laboratory Practice Standards Branch, 

Division of Laboratory Science and 

Standards, Laboratory Science, Policy 

and Practice Program Office, Office of 

Surveillance, Epidemiology and 

Laboratory Services, Centers for Disease 

Control and Prevention, 1600 Clifton 

Road, NE., Mailstop F–11, Atlanta, 

Georgia 30333; telephone (404) 498– 

2741; fax (404) 498–2219; or via e-mail 

at Nancy.Anderson@cdc.hhs.gov. 

The Director, Management Analysis 

and Services Office, has been delegated 

the authority to sign Federal Register 

Notices pertaining to announcements of 

meetings and other committee 

management activities, for the Centers 

for Disease Control and Prevention and 

the Agency for Toxic Substances and 

Disease Registry. 

Dated: February 14, 2011. 

Elaine L. Baker, 

Director, Management Analysis and Services 

Office, Centers for Disease Control and 

Prevention. 

[FR Doc. 2011–3707 Filed 2–17–11; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10251] 

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: Integrated 

Medicare and Medicaid State Plan 

Preprint; Form No.: CMS–10251 (OMB#: 

0938–1047); Use: The Integrated Care 

Preprint is an optional tool for use by 

States to highlight the arrangements 

provided between the State and 

Medicare Advantage Special Needs 

Plans that are also providing Medicaid 

services. The preprint also provides the 

opportunity for States to confirm that 

their integrated care model complies 

with Federal statutory and regulatory 

requirements. State Medicaid Agencies 

may complete the preprint and CMS 

will review the information provided to 

determine if the State has properly 

completed and explained their 

integrated care arrangements and that 

the appropriate assurances have been 

met; Frequency: Once; Affected Public: 

State, Local, or Tribal Governments; 

Number of Respondents: 56; Total 

Annual Responses: 10; Total Annual 

Hours: 200. (For policy questions 

regarding this collection contact Mary 

Pat Farkas at 410–786–5731. 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 at 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 April 19, 2011: 

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, Room C4–26–05, 7500 

Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–3749 Filed 2–17–11; 8:45 am] 

BILLING CODE 4120–01–P 

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 Information Collection 

Activities: Submission for OMB 

Review; 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), 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 

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9580 Federal Register / Vol. 76, No. 34 / Friday, February 18, 2011 / Notices 

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 

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Federal Register / Vol. 76, No. 34 / Friday, February 18, 2011 / Notices 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 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Submission for OMB Review; 

Comment Request 

Title: Strengthening Communities 

Fund (SCF) Performance Management 

and Evaluation Support. 

OMB No.: New Collection. 

Description: This proposed 

information collection activity is to 

obtain information from participants in 

two Strengthening Communities Fund 

(SCF) programs: The Nonprofit Capacity 

Building Program and the State, Local, 

and Tribal Government Capacity 

Building Program. Both programs are 

designed to contribute to the economic 

recovery as authorized in the American 

Recovery and Reinvestment Act of 2009 

(ARRA). The SCF evaluation is an 

important opportunity to examine 

outcomes achieved by the Strengthening 

Communities Fund and progress toward 

the objective of improving the capacity 

of organizations served by program 

grantees to address broad economic 

recovery issues in their communities. 

The evaluation will be designed to 

assess progress and measure increased 

organizational capacity of each 

participating organization. The purpose 

of this request is to receive approval of 

the data collection instruments that will 

be used in this study. 

A significant amount of information is 

already being collected through 

program-specific OMB-approved PPR 

forms or is available through secondary 

sources. Proposed surveys and phone 

interviews are very brief to reduce the 

burden on respondents. 

Respondents: 

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