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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services 

          - [Document Identifier: CMS-10172, CMS-R-0107 and CMS-R-285] 

# 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:*                     New Collection;                     *Title of Information Collection:*                     Medicare Health Support Program Medical Records Abstraction;                     *Form Number:*                     CMS-10172 (OMB#: 0938-New);                     *Use:*                     The Medicare Health Support Program (MHS) is authorized under Section 721 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). There are eight Medicare Health Support Organizations (MHSOs) that have signed cooperative agreements with the Centers for Medicare & Medicaid Services (CMS) to provide care support services to targeted Medicare fee-for-service (FFS) beneficiaries. The purposes of the MHS program are to improve the quality of healthcare provided to Medicare FFS beneficiaries with congestive heart failure and/or diabetes and to reduce the healthcare treatment cost to Medicare. MHS performance measures provide CMS with information to monitor the program operations and identify positive or negative program effects, provide MHSOs with feedback, and serve as the basis for MHS performance guarantees. To meet these requirements, CMS has developed a performance monitoring system for MHS. This system includes measures of clinical performance that require the collection of clinical data from the medical records of a sample of Medicare beneficiaries. Medical record abstraction will be performed in two phases: the first, a pilot test, will take place after approximately six months of program operations, and the second, the full study. CMS will obtain active informed consent from the affected beneficiaries prior to reviewing medical records;                     *Frequency:*                     Reporting—Other: Only Once;                     *Affected Public:*                     Individuals or Households and Business or other for-profit;                     *Number of Respondents:*                     26,643;                     *Total Annual Responses:*                     26,643; Total Annual Hours: 12,416.                 

                    2.                     *Type of Information Collection Request:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Medicare—Determining Third Party Liability (TPL) State Plan Preprint and Supporting Regulations in 42 CFR 433.138;                     *Form Number:*                     CMS-R-0107 (OMB#: 0938-0502);                     *Use:*                     Medicaid beneficiaries frequently have third party resources which are legally obligated to pay medical claims before Medicaid pays. Section 42 CFR 433.138 requires State Medicaid agencies to take specific steps to identify third party resources and determine their legal liability to pay for services under the plan. The collection of TPL information results in significant program savings to the extent that liable third parties can be identified and payments can be made for services that would otherwise be paid for by the Medicaid program. The State Medicaid agencies are the primary users of the collected data. Whenever States identify third party resources, pertinent information is entered into the State's Medicaid Management Information System (MMIS). This enables the State to advise the provider to bill the third party and to seek reimbursement in situations where Medicaid TPL claims have been paid;                     *Frequency:*                     Recordkeeping—On occasion;                     *Affected Public:*                     Individuals or Households and Federal, State, Local and Tribal Government;                     *Number of Respondents:*                     2,700,000;                     *Total Annual Responses:*                     2,700,000; Total Annual Hours: 472,259.                 

                    3.                     *Type of Information Collection Request:*                     Extension of a currently                           ( print page 61292)                        approved collection;                     *Title of Information Collection:*                     Request for Retirement Benefit Information (BBA ‘97);                     *Form Number:*                     CMS-R-285 (OMB#: 0938-0769);                     *Use:*                     The Request for Retirement Benefit Information form is used to obtain retirement benefit information from beneficiaries that purchase Medicare Part A coverage. The Social Security Administration (SSA) will use this information to determine if a beneficiary meets the requirements to qualify for a Medicare Part A premium reduction.;                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     State, Local or Tribal Government;                     *Number of Respondents:*                     1500;                     *Total Annual Responses:*                     1500; Total Annual Hours: 375.                 

                    To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS'l Web site address at                     *http://www.cms.hhs.gov/​regulations/​pra/​,*                     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 at the address below, no later than 5 p.m. on December 20, 2005. CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Bonnie L Harkless, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 

Dated: October 13, 2005. 

Michelle Shortt, 

Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs. 

[FR Doc. 05-20962 Filed 10-20-05; 8:45 am] 

BILLING CODE 4120-01-P