Federal Register / Vol. 75, No. 171 / Friday, September 3, 2010 / Notices 54149 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare and Medicaid 

Services 

[Document Identifier: CMS–417, CMS–10227 

and CMS–10351] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Centers for Medicare & 

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) 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: Hospice Request 

for Certification in the Medicare 

Program; Use: The Hospice Request for 

Certification Form is the identification 

and screening form used to initiate the 

certification process and to determine if 

the provider has sufficient personnel to 

participate in the Medicare program. 

Form Number: CMS–417 (OMB#: 0938– 

0313); Frequency: Annually; Affected 

Public: Private Sector: Business or other 

for-profits; Number of Respondents: 

3,494; Total Annual Responses: 3,494; 

Total Annual Hours: 594. (For policy 

questions regarding this collection 

contact Debbie Terkay at 410–786–6835. 

For all other issues call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: PACE State Plan 

Amendment Pre-print; Use: The 

Balanced Budget Act of 1997 created 

section 1934 of the Social Security Act 

that established the Program for the AllInclusive Care for the Elderly (PACE). 

The legislation established the PACE 

program as a Medicaid State plan option 

serving the frail and elderly in the home 

and community. Pursuant to the notice 

given in 64 FR 66271 (November 24, 

1999), if a State elects to offer PACE as 

an optional Medicaid benefit, it must 

complete a State Plan Amendment 

described as Enclosures #3, 4, 5, 6 and 

7. The information collected is used by 

CMS to affirm that the State elects to 

offer PACE an optional State plan 

service and the specifications of 

eligibility, payment and enrollment for 

the program. Form Number: CMS–10227 

(OMB#: 0938–1027); Frequency: Once; 

Affected Public: State, Local, or Tribal 

Governments; Number of Respondents: 

36; Total Annual Responses: 12; Total 

Annual Hours: 240. (For policy 

questions regarding this collection 

contact Angela Taube at 410–786–2638. 

For all other issues call 410–786–1326.) 

3. Type of Information Collection 

Request: New collection; Title of 

Information Collection: ESRD PPS 

Transition Election and attestations of 

Low-Volume; Use: The Medicare 

Improvement for Patients and Providers 

Act (MIPPA) requires implementation of 

an End Stage Rental Disease (ESRD) 

bundled prospective payment system 

(PPS) effective January 1, 2011. Once 

implemented, the ESRD PPS will 

replace the current basic case-mix 

adjusted composite payment system and 

the methodologies for the 

reimbursement of separately billable 

outpatient ESRD related items and 

services. The ESRD PPS will provide a 

single payment to the ESRD facilities 

that will cover all the resources used in 

providing an outpatient dialysis 

treatment. Also, as required my MIPPA, 

ESRD facilities are eligible to receive a 

low-volume adjustment when the 

facility furnished less than 4000 

treatments in each of the three years 

pre-ceding the payment year. 

In order for an ESRD facility to 

receive the low-volume adjustment, 

CMS will require that an ESRD facility 

must provide an attestation to the fiscal 

intermediary or the Medicare 

administrative contractor (FI/MAC) that 

it has met the criteria to qualify as a 

low-volume facility. The FI or MAC 

would verify the ESRD facility’s 

attestation of their low-volume status 

using the ESRD facility’s final-settled 

cost reports. Also, an ESRD facility may 

make a one-time election to be excluded 

from the four-year transition to the 

ESRD PPS. A facility may elect to be 

paid entirely based on the ESRD PPS 

beginning January 1, 2011. If the ESRD 

facility fails to submit an election, or the 

ESRD facility’s election is not received 

by their MAC by November 1, 2010, 

payments to the ESRD facility for items 

and services provided during the 

transition will be paid under the basic 

case-mix adjusted composite payment 

system. Form Number: CMS–10351 

(OMB#: 0938–New); Frequency: 

Annually; Affected Public: Private 

Sector: Business or other for-profits and 

Not-for-profit institutions; Number of 

Respondents: 5,808; Total Annual 

Responses: 2,520; Total Annual Hours: 

563.2. (For policy questions regarding 

this collection contact Janet Samen at 

410–786–4533. 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 November 2, 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: August 26, 2010. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2010–21722 Filed 9–2–10; 8:45 am] 

BILLING CODE 4120–01–P 


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