Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 38207 

9Staff will enter data on flexible funds expenditures into a Web-based application or will recode existing data on flexible funds expenditures to 

match the Flex Funds Data Dictionary format. Each community will use flexible funds expenditures on average for approximately one-quarter of 

the estimated 356 children/youth enrolled, suggesting a total of 89 children/youth will receive services from flexible funds per community. Thus, 

there will be data entered for 89 × 30 = 2,670 children/youth using the Flex Funds Data Dictionary. 10Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund benefits. 11Staff will collect paper-based forms from agencies and enter them into a Web-based application or will extract data from agencies’ existing 

data systems. Staff will recode data to match the Services and Costs Data Dictionary format. Service and costs records will be compiled for all 

356 × 30 = 10,680 children/youth enrolled. 12Assumes that each child/youth will have 100 service episodes, on average, during his/her time in a system of care. 13This survey will be administered in 5 communities funded in 2006, 25 communities funded in 2005, 2 communities funded in 2000, and 20 

communities funded in 1999. For each community, one respondent will be a caregiver and three respondents will be administrators/providers. 

Written comments and 

recommendations concerning the 

proposed information collection should 

be sent by August 31, 2009 to: SAMHSA 

Desk Officer, Human Resources and 

Housing Branch, Office of Management 

and Budget, New Executive Office 

Building, Room 10235, Washington, DC 

20503; due to potential delays in OMB’s 

receipt and processing of mail sent 

through the U.S. Postal Service, 

respondents are encouraged to submit 

comments by fax to: 202–395–6974. 

Dated: July 27, 2009. 

Elaine Parry, 

Director, Office of Program Services. 

[FR Doc. E9–18315 Filed 7–30–09; 8:45 am] 

BILLING CODE 4162–20–P 

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#: 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 (premiumPart 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#: 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#: 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: 


PWALKER on DSK8KYBLC1PROD with NOTICES
38208 Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 

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#: 0938–0781); Frequency: 

Reporting—Hourly, Daily, Weekly, 

Monthly, Yearly, Quarterly, Semiannually, 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 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 August 31, 2009. 

OMB, Office of Information and 

Regulatory Affairs, Attention: CMS 

Desk Officer, Fax Number: (202) 395– 

6974, e-mail: 

OIRA_submission@omb.eop.gov. 

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 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10191] 

Agency Information Collection 

Activities: Proposed Collection; 

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) 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: Revision of a currently 

approved collection; Title of 

Information Collection: Medicare Parts 

C and D Universal Audit Guide; Use: 

Under the Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003 and implementing regulations at 

42 CFR Parts 422 and 423 Medicare Part 

D plan sponsors and Medicare 

Advantage organizations are required to 

comply with all Medicare Parts C and D 

program requirements. 42 CFR 422.502 

describes CMS’ regulatory authority to 

evaluate, through inspection or other 

means, Medicare Advantage Part C 

organizations. These records include 

books, contracts, medical records, 

patient care documentation and other 

records that pertain to any aspect of 

services performed, reconciliation of 

benefit liabilities, and determination of 

amounts payable. 42 CFR 423.503 states 

that CMS must oversee a Part D plan 

sponsor’s continued compliance with 

the requirements for a Part D plan 

sponsor. § 423.514 states that the Part D 

plan sponsor must have an effective 

procedure to develop, compile, 

evaluate, and report to CMS, to its 

enrollees, and to the general public, at 

the times and in the manner that CMS 

requires, statistics regarding areas such 

as cost of operations, patterns of 

utilization availability, accessibility, 

and acceptability of services. 

The explosive growth of these 

sponsoring organizations has forced 

CMS to update its current auditing 

strategy to ensure we continue to obtain 

meaningful audit results. As a result, 

CMS’ audit strategy will reflect a move 

away from routine audits to more 

targeted, data-driven and risk-based 

audits. CMS will also focus on high-risk 

areas that have the greatest potential for 

beneficiary harm. The goal of the audits 

will be the earliest possible detection 

and correction of issues and 

improvement in quality and 

performance of Part D sponsors and 

Medicare Advantage organizations. 

To accomplish these goals, we have 

combined all Part C and Part D audit 

elements into one universal guide 

which will also promote consistency, 

effectiveness and reduce financial and 

time burdens for both CMS and 

Medicare-contracting entities. Please 

refer to the crosswalk document for a 

list of changes. Form Number: CMS– 

10191 (OMB#: 0938–1000); Frequency: 

Reporting—Yearly; Affected Public: 

Business or other for-profits and Notfor-profit institutions; Number of 

Respondents: 195; Total Annual 

Responses: 195; Total Annual Hours: 

24,180. (For policy questions regarding 

this collection contact Laura Dash at 

410–786–8623. 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 September 29, 2009: 

1. Electronically. You may submit 

your comments electronically to http:// 

www.regulations.gov. Follow the 


PWALKER on DSK8KYBLC1PROD with NOTICES