```

[Federal Register: April 19, 2010 (Volume 75, Number 74)]
[Notices]               
[Page 20366-20367]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr19ap10-41]                         

-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-416 and CMS-R-297]

 
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 & 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: Annual Early and 
Periodic Screening, Diagnostic and Treatment (EPSDT) Services 
Participation Report; Form Number: CMS-416 (OMB: 0938-0354); 
Use: States are required to submit an annual report on the provision of 
EPSDT services pursuant to section 1902(a)(43)(D) of the Social 
Security Act. These reports provide CMS with data necessary to assess 
the effectiveness of State EPSDT programs, to determine a State's 
results in achieving its participation goal and to respond to 
inquiries. Respondents are State Medicaid Agencies. The data is due 
April 1 of every year so States need to have the form and instructions 
as soon as possible in order to report timely. Frequency: Yearly; 
Affected Public: State, Tribal and Local governments; Number of 
Respondents: 56; Total Annual Responses: 112; Total Annual Hours: 
1,568. (For policy questions regarding this collection contact Cindy 
Ruff at 410-786-5916. For all other issues call 410-786-1326.)
    2. 1. Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: Request 
for Employment Information; Use: Section 1837(i) of the Social Security 
Act provides for a special enrollment period for individuals who delay 
enrolling in Medicare Part B because they are covered by a group health 
plan based on their own or a spouse's current employment status. When 
these individuals apply for Medicare Part B, they must provide proof 
that the group health plan coverage is (or was) based on current 
employment status. This form is used by the Social Security 
Administration to obtain information from employers regarding whether a 
Medicare beneficiary's coverage under a group health plan is based on 
current employment status. Form Number: CMS-R-297 (OMB: 0938-
0787); Frequency: Once; Affected Public: Private Sector: Business or 
other for-profits and Not-for-profit institutions; Number of 
Respondents: 5,000; Total Annual Responses: 5,000; Total Annual Hours: 
1,250. (For policy questions regarding this collection contact Kevin

[[Page 20367]]

Simpson at 410-786-0017. 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 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.
    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 June 18, 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: April 9, 2010.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. 2010-8901 Filed 4-16-10; 8:45 am]
BILLING CODE 4120-01-P
```