[Federal Register Volume 74, Number 146 (Friday, July 31, 2009)]
[Notices]
[Pages 38207-38208]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-18379]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-43, CMS-1763, CMS-R-194 and CMS-R-296]


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: Extension of a currently 
approved collection; Title of Information Collection: Application for 
Hospital Insurance Benefits for Individuals with End Stage Renal 
Disease: Use: Effective July 1, 1973, individuals with End Stage Renal 
Disease (ESRD) became entitled to Medicare. Because this entitlement 
has a different set of requirements, the existing applications for 
Medicare were not sufficient to capture the information needed to 
determine Medicare entitlement under the ESRD provisions of the law. 
The Application for Hospital Insurance Benefits for Individuals with 
End Stage Renal Disease, was designed to capture all the information 
needed to make a Medicare entitlement determination; Form Numbers: CMS-
43 (OMB<greek-i>: 0938-0800; Frequency: Reporting--Once; Affected 
Public: Individuals or households; Number of Respondents: 60,000; Total 
Annual Responses: 60,000; Total Annual Hours: 25989. (For policy 
questions regarding this collection contact Naomi Rappaport at 410-786-
2175. For all other issues call 410-786-1326.)
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Termination of Premium Hospital and/or Supplementary Medical Insurance: 
Use: The Social Security Act (the Act) allows a Medicare enrollee to 
voluntarily terminate Supplementary Medical Insurance (Part B) and/or 
the premium Hospital Insurance (premium-Part A) coverage by filing a 
written request with CMS or the Social Security Administration (SSA). 
The Act also stipulates when coverage will end based upon the date the 
request was filed. Because Medicare is recognized as a valuable 
protection against the high cost of medical and hospital bills, when an 
individual wishes to voluntarily terminate Part B and/or premium Part 
A, CMS and SSA requests the reason that an individual wishes to 
terminate coverage to ensure that the individual understands the 
ramifications of the decision. The Request for Termination of Premium 
Hospital and/or Supplementary Medical Insurance, provides a 
standardized form to satisfy the requirements of law as well as 
allowing both agencies to protect the individual from an inappropriate 
decision; Form Numbers: CMS-1763 (OMB<greek-i>: 0938-0025; Frequency: 
Reporting--Once; Affected Public: Individuals or households; Number of 
Respondents: 14,000; Total Annual Responses: 14,000; Total Annual 
Hours: 5,831. (For policy questions regarding this collection contact 
Naomi Rappaport at 410-786-2175. For all other issues call 410-786-
1326.)
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicare 
Disproportionate Share Adjustment Procedures and Criteria and 
Supporting Regulations in 42 CFR 412.106: Use: Section 1886(d)(5)(F) of 
the Social Security Act established the Medicare disproportionate share 
adjustment (DSH) for hospitals, which provides additional payment to 
hospitals that serve a disproportionate share of the indigent patient 
population. This payment is an add-on to the set amount per case CMS 
pays to hospitals under the Medicare Inpatient Prospective Payment 
System (IPPS).
    Under current regulations at 42 CFR 412.106, in order to meet the 
qualifying criteria for this additional DSH payment, a hospital must 
prove that a disproportionate percentage of its patients are low income 
using Supplemental Security Income (SSI) and Medicaid as proxies for 
this determination. This percentage includes two computations: (1) The 
``Medicare fraction'' or the ``SSI ratio'' which is the percent of 
patient days for beneficiaries who are eligible for Medicare Part A and 
SSI and (2) the ``Medicaid fraction'' which is the percent of patient 
days for patients who are eligible for Medicaid but not Medicare. Once 
a hospital qualifies for this DSH payment, CMS also determines a 
hospital's payment adjustment; Form Numbers: CMS-R-194 (OMB<greek-i>: 
0938-0691; Frequency: Reporting--Occasionally; Affected Public: 
Business or other for-profit and Not-for-profit institutions; Number of 
Respondents: 800; Total Annual Responses: 800; Total Annual Hours:

[[Page 38208]]

400. (For policy questions regarding this collection contact JoAnn 
Cerne at 410-786-4530. For all other issues call 410-786-1326.)
    4. Type of Information Collection Request: Revision of a currently 
approved Collection; Title of Information Collection: Home Health 
Advance Beneficiary Notice (HHABN); Use: Home health agencies (HHAs) 
are required to provide written notice to Medicare beneficiaries under 
various circumstances involving the initiation, reduction, or 
termination of services. The vehicle used in these situations is the 
Home Health Advance Beneficiary Notice (HHABN). The notice is designed 
to ensure that beneficiaries receive complete and useful information 
regarding potential financial liability or any changes made to their 
plan of care (POC) to enable them to make informed consumer decisions. 
The notice must provide clear and accurate information about the 
specified services and, when applicable, the cost of services when 
Medicare denial of payment is expected by the HHA. Form Number: CMS-R-
296 (OMB<greek-i>: 0938-0781); Frequency: Reporting--Hourly, Daily, 
Weekly, Monthly, Yearly, Quarterly, Semi-annually, Biennially, Once and 
Occasionally; Affected Public: Business or other for-profits and Not-
for-profit institutions; Number of Respondents: 9024; Total Annual 
Responses: 12,349,787; Total Annual Hours: 1,028,737. (For policy 
questions regarding this collection contact Evelyn Blaemire at 410-786-
1803. 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 <a href="/cdn-cgi/l/email-protection#ebbb8a9b8e999c849980ab888698c5838398c58c849d"><span class="__cf_email__" data-cfemail="8cdcedfce9fefbe3fee7ccefe1ffa2e4e4ffa2ebe3fa">[email protected]</span></a>, 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 August 31, 2009.

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk 
Officer, Fax Number: (202) 395-6974, e-mail: <a href="/cdn-cgi/l/email-protection#6e21273c2f311d1b0c03071d1d0701002e01030c400b011e40090118"><span class="__cf_email__" data-cfemail="a5eaecf7e4fad6d0c7c8ccd6d6cccacbe5cac8c78bc0cad58bc2cad3">[email protected]</span></a>.

    Dated: July 23, 2009.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. E9-18379 Filed 7-30-09; 8:45 am]
BILLING CODE 4120-01-P


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