22932 Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices 

FR 28471–72) soliciting public 

comments on a proposal to introduce a 

cost sharing requirement for the HPP 

program. Twenty-eight comments were 

received from hospitals, hospital 

associations, State Health Officials, and 

professional organizations. The 

comments received included concerns 

about finding the resources needed to 

cost share, additional administrative 

recordkeeping related to cost sharing, 

and overall decreased participation in 

the HPP. In response, HHS believes the 

concerns that were raised about 

awardees finding the resources needed 

to cost share, additional administrative 

recordkeeping, and a potential for 

decreased participation in the HPP are 

outweighed by the benefits a cost 

sharing requirement will bring to HPP. 

The cost sharing requirement will be a 

concrete way of solidifying 

collaboration between States and the 

Federal government in assuring this 

program will achieve enhanced 

sustainability in healthcare system 

preparedness during and after the 

project period has ended. 

Thus, HPP cooperative agreement 

recipients will be required to contribute 

non-Federal matching funds starting 

with the FY 2009 funding cycle and 

each year thereafter. Awardees will be 

required to make available, either 

directly or through donations from 

public or private entities, non-Federal 

contributions in an amount equal to five 

percent of the award amount in FY 2009 

and ten percent of the award amount in 

FY 2010 and each successive year for 

the duration of the program. NonFederal contributions will be provided 

directly or through donations from 

public or private entities and may be in 

cash or in kind, fairly evaluated, 

including plant, equipment or services. 

Amounts provided by the Federal 

government, or services assisted or 

subsidized to any significant extent by 

the Federal government, may not be 

included in determining the amount of 

such non-Federal contributions. 

The cost sharing requirement will 

apply to the entire award amount 

received by the awardee from the U.S. 

Department of Health and Human 

Services through the HPP. 

The cost sharing requirement will be 

enforced as a term and condition of the 

HPP award. 

Dated: May 8, 2009. 

William C. Vanderwagen, 

Assistant Secretary for Preparedness and 

Response, U.S. Department of Health and 

Human Services. 

[FR Doc. E9–11307 Filed 5–14–09; 8:45 am] 

BILLING CODE 4150–37–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–276, CMS–43, 

CMS–1763, CMS–R–194, CMS–R–232, and 

CMS–R–296] 

Agency Information Collection 

Activities: Proposed Collection; 

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) 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: Prepaid Health 

Plan Cost Report; Use: Health 

Maintenance Organizations and 

Competitive Medical Plans (HMO/ 

CMPs) contracting with the Secretary 

under Section 1876 of the Social 

Security Act are required to submit a 

budget and enrollment forecast, four 

quarterly reports and a final certified 

cost report. Health Care Prepayment 

Plans (HCPPs) contracting with the 

Secretary under Section 1833 of the 

Social Security Act are required to 

submit a budget and enrollment 

forecast, mid-year report, and final cost 

report. An HMO/CMP is a health care 

delivery system that furnishes directly 

or arranges for the delivery of the full 

spectrum of health services to an 

enrolled population. A HCPP is a health 

care delivery system that furnishes 

directly or arranges for the delivery of 

certain physician and diagnostics 

services up to the full spectrum of nonprovider Part B health services to an 

enrolled population. These reports will 

be used to establish the reasonable cost 

of delivering covered services furnished 

to Medicare enrollees by an HMO/CMP 

or HCPP.; Form Numbers: CMS–276 

(OMB #: 0938–0165); Frequency: 

Recordkeeping, Reporting—Quarterly 

and Annually; Affected Public: Business 

or other for-profit; Number of 

Respondents: 35; Total Annual 

Responses: 128; Total Annual Hours: 

5,285. (For policy questions regarding 

this collection contact Temeshia 

Johnson at 410–786–8692. For all other 

issues call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Application for 

Hospital Insurance Benefits for 

Individuals with End Stage Renal 

Disease: Use: Effective July 1, 1973, 

individuals with End Stage Renal 

Disease (ESRD) became entitled to 

Medicare. Because this entitlement has 

a different set of requirements, the 

existing applications for Medicare were 

not sufficient to capture the information 

needed to determine Medicare 

entitlement under the ESRD provisions 

of the law. The Application for Hospital 

Insurance Benefits for Individuals with 

End Stage Renal Disease, was designed 

to capture all the information needed to 

make a Medicare entitlement 

determination; Form Numbers: CMS–43 

(OMB #: 0938–0800; Frequency: 

Reporting—Once; Affected Public: 

Individuals or households; Number of 

Respondents: 60,000; Total Annual 

Responses: 60,000; Total Annual Hours: 

25989. (For policy questions regarding 

this collection contact Naomi Rappaport 

at 410–786–2175. For all other issues 

call 410–786–1326.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Request for 

Termination of Premium Hospital and/ 

or Supplementary Medical Insurance: 

Use: The Social Security Act (the Act) 

allows a Medicare enrollee to 

voluntarily terminate Supplementary 

Medical Insurance (Part B) and/or the 

premium Hospital Insurance 

(premium—Part A) coverage by filing a 

written request with CMS or the Social 

Security Administration (SSA). The Act 

also stipulates when coverage will end 

based upon the date the request was 

filed. Because Medicare is recognized as 

a valuable protection against the high 

cost of medical and hospital bills, when 

an individual wishes to voluntarily 

terminate Part B and/or premium Part 

A, CMS and SSA requests the reason 

that an individual wishes to terminate 

coverage to ensure that the individual 

understands the ramifications of the 

decision. The Request for Termination 

of Premium Hospital and/or 

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