[Federal Register Volume 74, Number 93 (Friday, May 15, 2009)]
[Notices]
[Pages 22932-22933]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-11422]


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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 non-
provider 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 <greek-i>: 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 <greek-i>: 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

[[Page 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 <greek-i>: 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 <greek-i>: 
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 <greek-i>: 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 <greek-i>: 0938-0781); Frequency: Reporting--Hourly, Daily, 
Weekly, Monthly, Yearly, Quarterly, Semi-annually, 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 e-
mail your request, including your address, phone number, OMB number, 
and CMS document identifier, to <a href="/cdn-cgi/l/email-protection#9dcdfcedf8efeaf2eff6ddfef0eeb3f5f5eeb3faf2eb"><span class="__cf_email__" data-cfemail="efbf8e9f8a9d98809d84af8c829cc187879cc1888099">[email protected]</span></a>, 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


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