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

**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 Actthat 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**