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

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

          - [Document Identifier: CMS-10001, CMS-10009, CMS-10272 and CMS-10242] 

# 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:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Health Insurance Portability and Accountability Act (HIPAA) Nondiscrimination Provisions and Supporting Regulations in 45 CFR 146.121(h) and 121(i)(2)(i);                     *Use:*                     If coverage has been denied to any individual because the sponsor of a self-funded non-Federal governmental plan had exempt the plan from the nondiscrimination requirements under 45 CFR 146.180 “Treatment of Non-Federal Governmental Plans”, and the plan sponsor subsequently chooses to bring the plan into compliance, the plan sponsor must comply with the requirements under 45 CFR 146.121(i)(2)(i) “Special Transitional Rule for Self-Funded Non-Federal Governmental Plans Exempted under 45 CFR 146.180”. To bring the plan into compliance with the requirements, the plan must notify the individual that the plan will be coming into compliance, afford the individual an opportunity to enroll, specify the effective date of compliance, and inform the individual regarding any enrollment restrictions that may apply under the terms of the plan once the plan is in compliance.                     *Form Number:*                     CMS-10001 (OMB# 0938-0827);                     *Frequency:*                     Yearly;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     18;                     *Total Annual Responses:*                     18;                     *Total Annual Hours:*                     194.                 

                    2.                     *Type of Information Collection Request:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Health Insurance Portability and Accountability Act (HIPAA) Nondiscrimination Provisions and Supporting Regulations in 45 CFR 146.121(f)(2)(v)(A);                     *Use:*                     Section 146.121 of the regulations requires Health plans or issuers to disclose in all plan materials the terms of certain wellness programs including the availability of a reasonable alternative standard. Plan participants and their dependents need this information to understand the rights they have under HIPAA. States and the Federal government may need the information supplied by issuers to properly perform their regulatory functions.                     *Form Number:*                     CMS-10009 (OMB# 0938-0819);                     *Frequency:*                     Yearly;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     2,600;                     *Total Annual Responses:*                     2,600;                     *Total Annual Hours:*                     1,300.                 

                    3.                     *Type of Information Collection Request:*                     New collection;                     *Title of Information Collection:*                     Hospital Leadership Quality Assessment Tool (HLQAT);                     *Use:*                     In 2006, the Hospital Leadership Collaborative (HLC) launched a public-private partnership to develop a CMS-endorsed self-assessment tool, “The Hospital Leadership and Quality Assessment Tool” (HLQAT) to assist hospitals in the improvement of quality through enhanced hospital governance,                           ( print page 57631)                        executive, physician, and clinical engagement. Hospitals leaders will take the HLQAT instrument via Web-based technology. This function will be carried out in conjunction with CMS and the Quality Improvement Organization (QIO) 9th Scope of Work (SOW), to convey the importance of this effort in relation to Medicare and other public priorities. This administration of the HLQAT seeks responses from approximately a dozen leaders in each hospital, including physicians (                    *e.g.*, CEO, CMO), board members, director-level, and mid-level clinical managers—these responses can provide a multi-level representation of hospital leadership showing its commitment to institutional change.                     *Form Number:*                     CMS-10272 (OMB# 0938-New);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     Private Sector—Business or Other for-profits;                     *Number of Respondents:*                     18,000;                     *Total Annual Responses:*                     36,000;                     *Total Annual Hours:*                     44,820.                 

                    4.                     *Type of Information Collection Request:*                     New collection;                     *Title of Information Collection:*                     Emergency and Non-Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b);                     *Use:*                     In the CY 2008 Physician Fee Schedule (PFS) final rule with comment period, we created an additional exception to the beneficiary signature requirements in § 424.36(b) for emergency ambulance transports (72 FR 66406). The exception allows ambulance providers and suppliers to sign the claim on behalf of the beneficiary, at the time of transport, provided that certain documentation requirements are met. Following publication of the CY 2008 PFS final rule with comment period, ambulance provider and supplier stakeholders requested that we extend the exception in § 424.36(b)(6) to non-emergency ambulance transports, in instances where the beneficiary is physically or mentally incapable of signing the claim form.                 

                    The current submission of this information collection request relates to the collection of documentation pertaining to non-emergency ambulance transports. In addition, we are updating the collection of information that relates to the collection of documentation pertaining to emergency ambulance transports.                     *Form Number:*                     CMS-10242 (OMB# 0938-1049);                     *Frequency:*                     Occasionally;                     *Affected Public:*                     Private Sector—Business or Other for-profits and Not-for-profit institutions;                     *Number of Respondents:*                     9,000;                     *Total Annual Responses:*                     13,185,835;                     *Total Annual Hours:*                     1,098,819.                 

                    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                     *December 2, 2008*.                 

                    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: September 26, 2008. 

Michelle Shortt, 

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

[FR Doc. E8-23414 Filed 10-2-08; 8:45 am] 

BILLING CODE 4120-01-P