Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices 22933 

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.) 

4. 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: 

400. (For policy questions regarding this 

collection contact JoAnn Cerne at 410– 

786–4530. For all other issues call 410– 

786–1326.) 

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare 

Integrity Program Organizational 

Conflict of Interest Disclosure Certificate 

and Supporting Regulations at 42 CFR 

421.300–421.316; Use: Section 

1893(d)(1) of the Social Security Act 

requires CMS to establish a process for 

identifying, evaluating, and resolving 

conflicts of interest. CMS proposed a 

process in Section 421.310 to mandate 

submission of pertinent information 

regarding conflicts of interest. The 

entities providing the information will 

be organizations that have been 

awarded, or seek award of, a Medicare 

Integrity Program contract. CMS needs 

this information to assess whether 

contractors who perform, or who seek to 

perform, Medicare Integrity Program 

functions, such as medical review, fraud 

review or cost audits, have 

organizational conflicts of interest and 

whether any conflicts have been 

resolved. Form Number: CMS–R–232 

(OMB #: 0938–0723); Frequency: 

Reporting—On occasion; Affected 

Public: Business or other for-profit; 

Number of Respondents: 11; Total 

Annual Responses: 44; Total Annual 

Hours: 2,200. (For policy questions 

regarding this collection contact Joe 

Strazzire at 410–786–2775. For all other 

issues call 410–786–1326.) 

6. 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, Semiannually, 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 

at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or email 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 July 14, 2009: 

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 (CMS–10283), Room 

C4–26–05, 7500 Security Boulevard, 

Baltimore, Maryland 21244–1850. 

Dated: May 7, 2009. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. E9–11422 Filed 5–14–09; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10237 and 

10214, and CMS–10171] 

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 

22934 Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices 

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: Medicare 

Advantage Applications—Part C and 

regulations under 42 CFR 422 subpart K; 

Use: The Balanced Budget Act of 1997 

established a new ‘‘Part C’’ in the 

Medicare statute Social Security Act 

(the Act), which provided for a 

Medicare+Choice (M+C) program. 

Under section 1851 of the Act, every 

individual entitled to Medicare Part A 

and enrolled under Part B, except for 

most individuals with end-stage renal 

disease (ESRD), could elect to receive 

benefits either through the Original 

Medicare Program or an M+C plan. 

The Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003 (MMA) was enacted on December 

8, 2003. The MMA established the 

Medicare Prescription Drug Benefit 

Program (Part D) and made revisions to 

the provisions of Medicare Part C, 

governing what is now called the 

Medicare Advantage (MA) program 

(formerly Medicare+Choice). 

Coverage for the prescription drug 

benefit is provided through contracted 

prescription drug plans or through 

Medicare Advantage (MA) plans that 

offer integrated prescription drug and 

health care coverage (MA–PD plans). 

Cost plans that are required under 

section 1876 of the Social Security Act, 

and Employer Group Waiver Plans 

(EGWP) may also provide a Part D 

benefit. Organizations wishing to 

provide services under the MA and 

MA–PD plans must complete an 

application, negotiate rates and receive 

final approval from CMS. Certain 

existing MA plans may also expand 

their contracted area by completing the 

Service Area Expansion (SAE) 

application. Form Number: CMS–10237 

and 10214 (OMB# 0938–0935); 

Frequency: Yearly; Affected Public: 

Private Sector; Number of Respondents: 

267; Total Annual Responses: 267; Total 

Annual Hours: 6,490. (For policy 

questions regarding this collection 

contact Betty Burrier at 410–786–4649. 

For all other issues call 410–786–1326.) 

2. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Coordination of 

Benefits between Part D Plans and Other 

Prescription Coverage Providers; Use: 

Section 1860D–23 and 1860D–24 of the 

Social Security Act requires the 

Secretary to establish requirements for 

prescription drug plans to ensure the 

effective coordination between Part D 

plans, State pharmaceutical Assistance 

programs and other payers. This 

collection request will assist CMS, Part 

D plans and other payers with 

coordination of prescription drug 

benefits at the point-of-sale and tracking 

of the beneficiary’s True out-of-pocket 

(TrOOP) expenditures using the TrOOP 

facilitator. This information will be used 

by Part D plans, other health insurers or 

payers, pharmacies and CMS to 

coordinate prescription drug benefits 

provided to the Medicare beneficiary. 

Beginning in CY 2009, CMS, via the 

TrOOP facilitation contractor, will 

automate the transfer of beneficiary 

coverage information when a 

beneficiary changes plans. Form 

Number: CMS–10171 (OMB# 0938– 

0978); Frequency: Hourly, yearly and 

occasionally; Affected Public: Business 

or other for-profits; Number of 

Respondents: 56,988; Total Annual 

Responses: 1,139,760; Total Annual 

Hours: 1,125,883. (For policy questions 

regarding this collection contact 

Christine Hinds at 410–786–4578. 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 June 15, 2009. 

OMB, Office of Information and 

Regulatory Affairs, Attention: CMS Desk 

Officer, Fax Number: (202) 395–6974, Email: OIRA_submission@omb.eop.gov. 

Dated: May 7, 2009. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. E9–11424 Filed 5–14–09; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Proposed Information Collection 

Activity; Comment Request 

Proposed Projects 

Title: Grant Application Data 

Summary (GADS) Form. 

OMB No.: 0970–0328. 

Description: The Grant Application 

Data Summary (GADS) form collects 

information from applicants seeking 

grants from the Administration for 

Native Americans (ANA). Applicants 

complete the GADS form as part of their 

funding package. This standardized 

format allows ANA to evaluate 

applications for financial assistance and 

to determine the relative focus of the 

projects for which such assistance is 

requested. The data collected focuses on 

the specific ANA program area for 

which the applicant is applying. ANA 

awards annual grants in the following 

nine competitive areas: (1) Social & 

Economic Develop Strategies (SEDS); (2) 

Alaska SEDS; (3) Special Initiative: 

Family Preservation: Improving the 

Well-Being of Children Planning; (4) 

Special Initiative: Family Preservation: 

Improving the Well-Being of Children 

Implementation; (5) Native Language 

Preservation & Maintenance 

Assessment; (6) Native Language 

Preservation & Maintenance Planning; 

(7) Native Language Preservation & 

Maintenance Implementation; (8) Native 

Language Preservation & Maintenance 

Immersion; (9) Environmental 

Regulatory Enhancement. 

Respondents: Federally Recognized 

Indian Tribes, Tribal Governments, 

Native American Non-profits, Tribal 

Colleges and Universities.