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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:

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                               ( print 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