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[Federal Register Volume 76, Number 34 (Friday, February 18, 2011)]
[Notices]
[Pages 9579-9581]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-3748]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-21 and -21B, CMS-37, CMS-64, CMS-10098, CMS-
10106, CMS-10120, CMS-10292, and CMS-10220]

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: Revision of a currently 
approved collection; Title of Information Collection: CMS-21 (Quarterly 
Children's Health Insurance Program (CHIP) Statement of Expenditures 
for the Title XXI Program) and CMS-21B (State Children's Health 
Insurance Program Budget Report for the Title XXI Program State Plan 
Expenditures); Use: Forms CMS-21 and -21B provide CMS with the 
information necessary to issue quarterly grant awards, monitor current 
year expenditure levels, determine the allowability of State claims for 
reimbursement, develop CHIP financial management information, provide 
for State reporting of waiver expenditures, and ensure that the 
Federally

[[Page 9580]]

established allotment is not exceeded. Further, these forms are 
necessary in the redistribution and reallocation of unspent funds over 
the Federally mandated timeframes; Form Numbers: CMS-21 and CMS-21B 
(OMB: 0938-0731); Frequency: Quarterly; Affected Public: 
State, Local, or Tribal Governments; Number of Respondents: 56; Total 
Annual Responses: 448; Total Annual Hours: 7,840. (For policy questions 
regarding this collection contact Jonas Eberly at 410-786-6232. For all 
other issues call 410-786-1326.)
    2. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Medicaid Program 
Budget Report; Use: Form CMS-37 is prepared and submitted to the 
Centers for Medicare & Medicaid Services (CMS) by State Medicaid 
agencies. Form CMS-37 is the primary document used by CMS in developing 
the national Medicaid budget estimates that are submitted to the Office 
of Management and Budget and the Congress; Form Number: CMS-37 
(OMB: 0938-0101); Frequency: Quarterly; Affected Public: 
State, Local, or Tribal Governments; Number of Respondents: 56; Total 
Annual Responses: 224; Total Annual Hours: 7,616. (For policy questions 
regarding this collection contact Jonas Eberly at 410-786-6232. For all 
other issues call 410-786-1326.)
    3. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Quarterly 
Medicaid Statement of Expenditures for the Medical Assistance Program; 
Use: Form CMS-64 has been used since January 1980 by the Medicaid State 
Agencies to report their actual program benefit costs and 
administrative expenses to CMS. CMS uses this information to compute 
the Federal financial participation for the State's Medicaid Program 
costs. Certain schedules of the CMS-64 form are used by States to 
report budget, expenditure and related statistical information required 
for implementation of the Medicaid portion of the State Children's 
Health Insurance Programs; Form Number: CMS-64 (OMB: 0938-
0067); Frequency: Quarterly; Affected Public: State, Local, or Tribal 
Governments; Number of Respondents: 56; Total Annual Responses: 224; 
Total Annual Hours: 16,464. (For policy questions regarding this 
collection contact Jonas Eberly at 410-786-6232. For all other issues 
call 410-786-1326.)
    4. Type of Information Collection Request: Reinstatement with 
change of a previously approved collection; Title of Information 
Collection: Beneficiary Satisfaction Survey; Use: The Beneficiary 
Satisfaction survey is performed to insure that the CMS 1-800-MEDICARE 
Helpline contractor is delivering satisfactory service to the Medicare 
beneficiaries. It gathers data on several Helpline operations such as 
print fulfillment and Web sites tool hosted on http://www.medicare.gov. 
Respondents to the survey are Medicare beneficiaries that have 
contacted 1-800-MEDICARE for information on benefits and services. CMS 
is seeking approval for additional questions to be added to the 
original collection entitled 800-Medicare Beneficiary Satisfaction 
survey. The original set of questions was used when placing outbound 
calls to callers regarding the service they received when they called 
the 800 Medicare Helpline with a Medicare question. The new expanded 
collection will include multiple survey methods to measure customer 
satisfaction not only with the Beneficiary Contact Center's (BCC's) 
handling of issues via telephone, but also the service provided to 
beneficiaries when they write a letter regarding their Medicare issue 
or use the e-mail and/or Web chat services provided by the BCC. The use 
of Customer Satisfaction Surveys is critical to the CMS mission to 
provide service to beneficiaries that is convenient, accessible, 
accurate, courteous, professional and responsive to the needs of 
diverse groups. Form Number: CMS-10098 (OMB: 0938-0919); 
Frequency: Weekly, Monthly, and Yearly; Affected Public: Individuals 
and Households; Number of Respondents: 36,144; Total Annual Responses: 
36,144; Total Annual Hours: 6,033. (For policy questions regarding this 
collection contact Mark Broccolino at 410-786-6128. For all other 
issues call 410-786-1326.)
    5. Type of Information Collection Request: Revision of currently 
approved collection; Title of Information Collection: Medicare 
Authorization to Disclose Personal Health Information; Use: Unless 
permitted or required by law, the Health Insurance Portability and 
Accountability Act (HIPAA) prohibits Medicare (a HIPAA covered entity) 
from disclosing an individual's protected health information without a 
valid authorization. In order to be valid, an authorization must 
include specified core elements and statements. Medicare will make 
available to Medicare beneficiaries a standard, valid authorization to 
enable beneficiaries to request the disclosure of their protected 
health information. This standard authorization will simplify the 
process of requesting information disclosure for beneficiaries and 
minimize the response time for Medicare. The completed authorization 
will allow Medicare to disclose an individual's personal health 
information to a third party at the individual's request. Form Number: 
CMS-10106 (OMB: 0938-0930); Frequency: Reporting--On occasion; 
Affected Public: Individuals or households; Number of Respondents: 
1,004,000; Total Annual Responses: 1,004,000; Total Annual Hours: 
251,000. (For policy questions regarding this collection contact 
Lindsay Dixon-Brown at 410-786-1178. For all other issues call 410-786-
1326.)
    6. Type of Information Collection Request: Extension without change 
of a currently approved collection; Title of Information Collection: 
1932 State Plan Amendment Template; Use: Section 1932(a)(1)(A) of the 
Social Security Act (the Act) grants states the authority to enroll 
Medicaid beneficiaries on a mandatory basis into managed care entities 
managed care organization (MCOs) and primary care case managers 
(PCCMs). Under this authority, a State can amend its Medicaid State 
plan to require certain categories of Medicaid beneficiaries to enroll 
in managed care entities without being out of compliance. This template 
may be used by States to easily modify their State plans if they choose 
to implement the provisions of section 1932(a)(1)(A).
    The State Medicaid Agencies will complete the template. CMS will 
review the information to determine if the State has met all the 
requirements of section 1932(a)(1)(A) and 42 CFR 438.50. If the 
requirements are met, CMS will approve the amendment to the State's 
title XIX plan giving the State the authority to enroll Medicaid 
beneficiaries on a mandatory basis into managed care entities MCOs and 
PCCMs. For a State to receive Medicaid funding, there must be an 
approved title XIX State plan; Form Number: CMS-10120 (OMB: 
0938-0933); Frequency: Occasionally; Affected Public: State, Local, or 
Tribal Governments; Number of Respondents: 56; Total Annual Responses: 
10; Total Annual Hours: 100. (For policy questions regarding this 
collection contact Camille Dobson at 410-786-7065. For all other issues 
call 410-786-1326.)
    7. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: State Medicaid 
Health Information Technology (HIT) Plan (SMHP) and Model Checklist: 
Health Information Technology (HIT) Planning-Advance Planning Document 
(HIT P-APD); Use: Section 4201 of

[[Page 9581]]

Recovery Act establishes 100 percent Federal financial participation 
(FFP) as reimbursement to States for making incentive payments to 
providers for meaningful use of certified electronic health record 
technology and 90 percent FFP for administering these payments. 
Additionally, States are required to conduct oversight of this program 
and ensure no duplicate payments; thus, CMS is requiring States to 
submit information to CMS for prior approval before drawing down 
funding. These documents, if States choose to implement these 
flexibilities, will require a collection of information to effectuate 
these changes.
    The State Medicaid agencies will complete the templates. CMS will 
review the information to determine if the State has met all of the 
requirements of the Recovery Act provisions the States choose to 
implement. If the requirements are met, CMS will approve the amendments 
giving the State the authority to implement their Health Information 
Technology (HIT) strategy and implementation plans. For a State to 
receive Medicaid Title XIX funding, there must be an approved State 
Medicaid HIT Plan, Planning Advance Planning Document and 
Implementation Advance Planning Document; Form Number: CMS-10292 
(OMB: 0938-1088); Frequency: Yearly, Once, Occasionally; 
Affected Public: State, Local, or Tribal Governments; Number of 
Respondents: 56; Total Annual Responses: 56; Total Annual Hours: 56. 
(For policy questions regarding this collection contact Sherry Armstead 
at 410-786-4342. For all other issues call 410-786-1326.)
    8. Type of Information Collection Request: Extension without change 
of a currently approved collection; Title of Information Collection: 
Provider Enrollment, Chain and Ownership System (PECOS) Security 
Consent Form; Use: The primary function of the Medicare enrollment 
application is to obtain information about the provider or supplier and 
whether the provider or supplier meets Federal and/or State 
qualifications to participate in the Medicare program. In addition, the 
Medicare enrollment application gathers information regarding the 
provider or supplier's practice location, the identity of the owners of 
the enrolling organization, and information necessary to establish the 
correct claims payment. In establishing a Web based application 
process, we allow providers and suppliers the ability to enroll in the 
Medicare program via the Internet. For these applicants, no security 
consent form is needed to enroll or make a change in their Medicare 
enrollment information. These applicants receive complete access to 
their own enrollments through Internet-based Provider Enrollment, Chain 
and Ownership System (PECOS).
    In order to allow a provider or supplier to delegate the Medicare 
credentialing process to another individual or organization, it is 
necessary to establish a Security Consent Form for those providers and 
suppliers who choose to have another individual or organization access 
their enrollment information and complete enrollments on their behalf. 
These users could consist of administrative staff, independent 
contractors, or credentialing departments and are represented as 
Employer Organizations. Employer Organizations and its members must 
request access to enrollment data through a Security Consent Form. The 
security consent form replicates business service agreements between 
Medicare applicants and organizations providing enrollment services.
    We are proposing two different versions of the Security Consent 
Form. The form, once signed, mailed and approved, grants an employer 
organization or its member's access to all current and future 
enrollment data for the Medicare provider. Form Number: CMS-10220 
(OMB: 0938-1035); Frequency: Occassionally; Affected Public: 
State, Local, or Tribal Governments; Number of Respondents: 197,500; 
Total Annual Responses: 197,500; Total Annual Hours: 49,375. (For 
policy questions regarding this collection contact Alisha Banks at 410-
786-0671. 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 March 21, 2011.
    OMB, Office of Information and Regulatory Affairs, Attention: CMS 
Desk Officer, Fax Number: (202) 395-6974, E-mail: OIRA_submission@omb.eop.gov.

Martique Jones,
Director, Regulations Development Group, Division B, Office of 
Strategic Operations and Regulatory Affairs.
[FR Doc. 2011-3748 Filed 2-17-11; 8:45 am]
BILLING CODE 4120-01-P
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