Document Headings

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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:

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 (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#: 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:*      ( print 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#: 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                     *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