Federal Register / Vol. 75, No. 59 / Monday, March 29, 2009 / Notices 15435 

extraordinarily high costs. To qualify for 

outlier payments, a case must have costs 

above a predetermined threshold 

amount (a dollar amount by which the 

estimated cost of a case must exceed the 

Medicare payment). Hospital-specific 

cost-to-charge ratios are applied to the 

covered charges for a case to determine 

the estimated cost of the case. In 

general, additional outlier payments for 

eligible cases are made based on a 

marginal cost factor of 80 percent, i.e. a 

fixed percentage of the costs. Therefore, 

if the estimated cost of the case exceeds 

the Medicare payment for that discharge 

plus the outlier threshold, generally 

Medicare will pay the hospital 80 

percent of the excess amount. The 

outlier threshold is updated annually at 

the beginning of the Federal Fiscal Year. 

Form Number: CMS–10179 (OMB #: 

0938–1020); Frequency: Occasionally; 

Affected Public: Private Sector and 

Business or other for-profits, Not-forprofit institutions; Number of 

Respondents: 18; Total Annual 

Responses: 18 Total Annual Hours: 144. 

(For policy questions regarding this 

collection contact Michael Treitel at 

410–786–4552. For all other issues call 

410–786–1326.) 

5. Type of Information Collection 

Request: Extension without change of a 

currently approved collection; Title of 

Information Collection: Subpart 

D—Private Contracts and Supporting 

Regulations contained in 42 CFR 

405.410, 405.430, 405.435, 405.440, 

405.445, and 405.455. Use: Section 4507 

of Balancing Budget Act (BBA) 1997 

amended section 1802 of the Social 

Security Act to permit certain 

physicians and practitioners to opt-out 

of Medicare and to provide through 

private contracts services that would 

otherwise be covered by Medicare. 

Under such contracts the mandatory 

claims submission and limiting charge 

rules of section 1848(g) of the Act would 

not apply. Subpart D and the 

Supporting Regulations contained in 42 

CFR 405.410, 405.430, 405.435, 405.440, 

405.445, and 405.455, counters the 

effect of certain provisions of Medicare 

law that, absent section 4507 of BBA 

1997, preclude physicians and 

practitioners from contracting privately 

with Medicare beneficiaries to pay 

without regard to Medicare limits. Form 

Number: CMS–R–234 (OMB#: 0938– 

0730); Frequency: Biennially; Affected 

Public: Private Sector and Business or 

other for-profits; Number of 

Respondents: 26,820; Total Annual 

Responses: 26,820; Total Annual Hours: 

7,197. (For policy questions regarding 

this collection contact Fred Grabau at 

410–786–0206. 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: Skilled Nursing 

Facility and Skilled Nursing Facility 

Health Care Complex Cost Report. Use: 

Providers of services participating in the 

Medicare program are required under 

sections 1815(a), 1833(e) and 

1861(v)(1)(A) of the Social Security Act 

(42 USC 1395g) to submit annual 

information to achieve settlement of 

costs for health care services rendered to 

Medicare beneficiaries. Form Number: 

CMS–2540 (OMB#: 0938–0463); 

Frequency: Yearly; Affected Public: 

Private Sector; Number of Respondents: 

15,071; Total Annual Responses: 

15,071; Total Annual Hours: 2,953,916 

(For policy questions regarding this 

collection contact Edwin Gill Sr. at 410– 

786–4525. 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 Email 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 May 28, 2010: 

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. 

Dated: March 19, 2010. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2010–7027 Filed 3–26–10; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10292, CMS– 

718–721 and CMS–685] 

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: New Collection; Title of 

Information Collection: State Medicaid 

HIT Plan and Templates for 

Implementation of Section 4201 of 

ARRA; Form Number: CMS–10292 

(OMB#: 0938–NEW); Use: This 

information is being requested in order 

that States can submit documentation to 

CMS for review and approval in order 

that States can implement the Medicaid 

program and draw down Federal 

financial participation. The American 

Reinvestment and Recovery Act of 2009 

(ARRA) provides States with the 

flexibility to request funds to develop a 

health information technology vision 

and road to get to the ultimate goal of 

meaningful use of certified electronic 

health records technology. We will be 

sending State Medicaid Directors letters 

and templates for the State Medicaid Hit 

Plan (SMHP), the Planning Advance 

Planning Document (PAPD) and the 

Implementation Advance Planning 

Document (IAPD) to States in an effort 

to request these changes if they so 

choose to make the process as simple as 

possible. Frequency: Yearly, once and/ 

or occasionally; Affected Public: State, 

Tribal and Local governments; Number 

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15436 Federal Register / Vol. 75, No. 59 / Monday, March 29, 2009 / Notices 

of Respondents: 56; Total Annual 

Responses: 56; Total Annual Hours: 

280. (For policy questions regarding this 

collection contact Donna Schmidt at 

410–786–5532. For all other issues call 

410–786–1326.) 

2. Type of Information Collection 

Request: Reinstatement with change of a 

previously approved collection; Title of 

Information Collection: Business 

Proposal Forms for Quality 

Improvement Organizations (QIOs); Use: 

The submission of proposal information 

by current quality improvement 

associations (QIOs) and other bidders, 

on the appropriate forms, will satisfy 

CMS’s need for meaningful, consistent, 

and verifiable data with which to 

evaluate contract proposals. The data 

collected on the forms associated with 

this information collection request is 

used by CMS to negotiate QIO contracts. 

The revised business proposal forms 

will be useful in a number of important 

ways. The Government will be able to 

compare the costs reported by the QIOs 

on the cost reports to the proposed costs 

noted on the business proposal forms. 

Subsequent contract and modification 

negotiations will be based on historic 

cost data. The business proposal forms 

will be one element of the historical cost 

data from which we can analyze future 

proposed costs. In addition, the 

business proposal format will 

standardize the cost proposing and 

pricing process among all QIOs. With 

well-defined cost centers and line items, 

proposals can be compared among QIOs 

for reasonableness and appropriateness. 

Form Number: CMS–718–721 (OMB#: 

0938–0579); Frequency: Reporting— 

Triennially; Affected Public: Business or 

other for-profits and Not-for-profit 

institutions; Number of Respondents: 

21; Total Annual Responses: 21; Total 

Annual Hours: 1,785. (For policy 

questions regarding this collection 

contact Clarissa Whatley at 410–786– 

7154. For all other issues call 410–786– 

1326.) 

3. Type of Information Collection 

Request: Reinstatement without change 

of a previously approved collection; 

Title of Information Collection: End 

Stage Renal Disease (ESRD) Network 

Semi-Annual Cost Report Forms and 

Supporting Regulations in 42 CFR 

405.2110 and 42 CFR 405.2112; Use: 

Section 1881(c) of the Social Security 

Act establishes End Stage Renal Disease 

(ESRD) Network contracts. The 

regulations found at 42 CFR 405.2110 

and 405.2112 designated 18 ESRD 

Networks which are funded by 

renewable contracts. These contracts are 

on 3-year cycles. To better administer 

the program, CMS is requiring 

contractors to submit semi-annual cost 

reports. The purpose of the cost reports 

is to enable the ESRD Networks to 

report costs in a standardized manner. 

This will allow CMS to review, compare 

and project ESRD Network costs during 

the life of the contract. Form Number: 

CMS–685 (OMB#: 0938–0657); 

Frequency: Reporting—Semi-annually; 

Affected Public: Not-for-profit 

institutions; Number of Respondents: 

18; Total Annual Responses: 36; Total 

Annual Hours: 108. (For policy 

questions regarding this collection 

contact Victoria Morgan at 410–786– 

7232. 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 email 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 April 28, 2010: OMB, Office of 

Information and Regulatory Affairs, 

Attention: CMS Desk Officer, Fax 

Number: (202) 395–6974, E-mail: 

OIRA_submission@omb.eop.gov. 

Dated: March 19, 2010. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2010–7033 Filed 3–26–10; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

Agency Information Collection 

Activities: Proposed Collection: 

Comment Request 

In compliance with the requirement 

for opportunity for public comment on 

proposed data collection projects 

(section 3506(c)(2)(A) of Title 44, United 

States Code, as amended by the 

Paperwork Reduction Act of 1995, Pub. 

L. 104–13), the Health Resources and 

Services Administration (HRSA) 

publishes periodic summaries of 

proposed projects being developed for 

submission to the Office of Management 

and Budget (OMB) under the Paperwork 

Reduction Act of 1995. To request more 

information on the proposed project or 

to obtain a copy of the data collection 

plans and draft instruments, e-mail 

paperwork@hrsa.gov or call the HRSA 

Reports Clearance Officer at (301) 443– 

1129. 

Comments are invited on: (a) The 

proposed collection of information for 

the proper performance of the functions 

of the agency; (b) the accuracy of the 

agency’s estimate of the burden of the 

proposed collection of information; (c) 

ways to enhance the quality, utility, and 

clarity of the information to be 

collected; and (d) ways to minimize the 

burden of the collection of information 

on respondents, including through the 

use of automated collection techniques 

or other forms of information 

technology. 

Proposed Project: Federally Qualified 

Health Centers (FQHC) Application 

Forms: (OMB No. 0915–0285 Revisions) 

HRSA’s Bureau of Primary Health 

Care Federally Qualified Health Centers 

(FQHCs) are a major component of 

America’s health care safety net, the 

Nation’s ‘‘system’’ of providing health 

care to low-income and other vulnerable 

populations. Health Centers care for 

people regardless of their ability to pay 

and whether or not they have health 

insurance. They provide primary and 

preventive health care, as well as 

services such as transportation and 

translation. Many Health Centers also 

offer dental, mental health and 

substance abuse care. 

FQHC’s are administered by the 

Health Resources and Services 

Administration’s (HRSA) Bureau of 

Primary Health Care (BPHC). HRSA uses 

the following application forms to 

administer and manage the FQHCs. 

These application forms are used by 

new and existing FQHCs to apply for 

grant and non-grant opportunities, 

renew their grant or non-grant 

opportunities or change their scope of 

project. 

Estimates of annualized reporting 

burden are as follows: 

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