34758 Federal Register / Vol. 74, No. 136 / Friday, July 17, 2009 / Notices 

1. Type of Information Collection 

Request: New Collection; Title of 

Information Collection: Children’s 

Health Insurance Program 

Reauthorization Act (CHIPRA) of 2009, 

State Option Pre-print to Include 

Pregnant Women in Title XXI; Use: 

Section 111 of CHIPRA adds a new 

section 2112 to the Social Security Act 

which gives States the option of 

providing necessary prenatal, delivery 

and postpartum care to low-income 

uninsured pregnant women through an 

amendment to its State Child Health 

Plan (CHIP plan). The purpose of this 

draft State plan amendment template is 

to provide States with the format 

needed to enable a State to amend their 

CHIP plan to reflect the coverage of 

pregnant women. Form Number: CMS– 

10284 (OMB#: 0938–NEW); Frequency: 

Reporting—One-time and Occasionally; 

Affected Public: State, Local or Tribal 

Government; Number of Respondents: 

40; Total Annual Responses: 40; Total 

Annual Hours: 3,200. (For policy 

questions regarding this collection 

contact Meredith Robertson at 410–786– 

6543. For all other issues call 410–786– 

1326.) 

2. Type of Information Collection 

Request: Reinstatement without change 

of a previously approved collection; 

Title of Information Collection: 

Statement of Deficiencies and Plan of 

Correction; Use: The information from 

the CMS–2567 is used by the States and 

CMS regional offices to document and 

certify compliance. Form Number: 

CMS–2567 (OMB#: 0938–0391); 

Frequency: Reporting—Annually; 

Affected Public: State, Local or Tribal 

Government, Federal Government, 

Business or other for-profits and Notfor-profit Institutions; Number of 

Respondents: 60,000; Total Annual 

Responses: 60,000; Total Annual Hours: 

120,000. (For policy questions regarding 

this collection contact Joanne Perry at 

410–786–3336. For all other issues call 

410–786–1326.) 

3. Type of Information Collection 

Request: New Collection; Title of 

Information Collection: State Plan 

Amendment Template for Transitional 

Medical Assistance for Low-Income 

Families; Use: Section 5004 of the 

American Recovery and Reinvestment 

Act of 2009, Public Law 111–5, amends 

section 1925 of the Social Security Act 

effective July 1, 2009 to offer States two 

new options for eligibility requirements 

under Transitional Medical Assistance. 

To select either or both of these options 

a State Medicaid Agency will complete 

the template page and submit it for 

approval as part of a State plan 

amendment. The law also imposes new 

reporting requirements for States which 

are mentioned on the template. Form 

Number: CMS–10283 (OMB#: 0938– 

NEW); Frequency: Reporting—One-time 

and Occasionally; Affected Public: State, 

Local or Tribal Government; Number of 

Respondents: 51; Total Annual 

Responses: 51; Total Annual Hours: 51. 

(For policy questions regarding this 

collection contact Mary Corddry at 410– 

786–6618. 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 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. 

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 August 17, 2009: OMB, Office of 

Information and Regulatory Affairs 

Attention: CMS Desk Officer, Fax 

Number: (202) 395–6974. 

E-mail: 

OIRA_submission@omb.eop.gov. 

Dated: July 9, 2009. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. E9–17080 Filed 7–16–09; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10260, CMS–R– 

72, CMS–10180 and CMS–R–199] 

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: Revision of a currently 

approved collection; Title of 

Information Collection: Medicare 

Advantage and Prescription Drug 

Program: Final Marketing Provisions 

CFR 422.111(a)(3) and 423.128(a)(3) 

Use: Medicare Advantage (MA) plans 

must provide notice to plan members of 

impending changes to plan benefits, 

premiums and copays in the coming 

year so that members will be in the best 

position to make an informed choice on 

continued enrollment or disenrollment 

from that plan at least 15 days before the 

Annual Election Period (AEP). 

Beginning 2009, organizations will be 

required to notify plan members of the 

coming year changes using a combined 

standardized document at the time of 

enrollment and annually thereafter. 

Section 422.111 requires, to the extent 

that a MA plan has a website, annual 

notification through the Web site of 

written, hard copy notification sent to 

the beneficiaries. Section 423.128 

requires that a Part D plan have 

mechanisms for providing specific 

information on a timely basis to current 

and prospective enrollees upon request. 

These mechanisms include, Internet 

website that includes information on 

Part D plan description. MA 

organizations (formerly M+C 

organizations) and Prescription Drug 

Plan Sponsors use the information to 

comply with the eligibility requirements 

and the MA and Part D contract 

requirements. CMS will use this 

information to ensure that correct 

information is disclosed to Medicare 

beneficiaries, both potential enrollees 

and enrollees. Form Number: CMS– 

10260 (OMB#: 0938–1051); Frequency: 

Reporting—Yearly; Affected Public: 

Business or other for-profits ; Number of 

Respondents: 740; Total Annual 

Responses: 740; Total Annual Hours: 

8,880. (For policy questions regarding 

this collection contact Camille Brown at 

410–786–0274. For all other issues call 

410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Information 

Collection Requirements in 42 CFR 

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Federal Register / Vol. 74, No. 136 / Friday, July 17, 2009 / Notices 34759 

478.18, 478.34, 478.36, 478.42, QIO 

Reconsiderations and Appeals; Use: In 

the event that a beneficiary, provider, 

physician, or other practitioner does not 

agree with the initial determination of a 

Quality Improvement Organization 

(QIO) or a QIO subcontractor, it is 

within that party’s rights to request 

reconsideration. The information 

collection requirements 42 CFR 478.18, 

478.34, 478.36, and 478.42, contain 

procedures for QIOs to use in 

reconsideration of initial 

determinations. The information 

requirements contained in these 

regulations are on QIOs to provide 

information to parties requesting the 

reconsideration. These parties will use 

the information as guidelines for appeal 

rights in instances where issues are 

actively being disputed.; Form Number: 

CMS–R–72 (OMB#: 0938–0443); 

Frequency: Reporting—On occasion; 

Affected Public: Individuals or 

Households and Business or other forprofit institutions; Number of 

Respondents: 2,590; Total Annual 

Responses: 5,228; Total Annual Hours: 

2,822. (For policy questions regarding 

this collection contact Tom Kessler at 

410–786–1991. For all other issues call 

410–786–1326.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Children’s 

Health Insurance Program (CHIP) Report 

on Payables and Receivables; Use: 

Collection of CHIP data and the 

calculation of the CHIP Incurred But 

Not Reported (IBNR) estimate are 

pertinent to CMS’ financial audit. The 

CFO auditors have reported the lack of 

an estimate for CHIP IBNR payables and 

receivables as a reportable condition in 

the FY 2005 audit of CMS’s financial 

statements. It is essential that CMS 

collect the necessary data from State 

agencies in FY 2006, so that CMS 

continues to receive an unqualified 

audit opinion on its financial 

statements. Program expenditures for 

the CHIP have increased since its 

inception; as such, CHIP receivables and 

payables may materially impact the 

financial statements. The CHIP Report 

on Payables and Receivables will 

provide the information needed to 

calculate the CHIP IBNR.; Form 

Number: CMS–10180 (OMB#: 0938– 

0988); Frequency: Reporting—Annually; 

Affected Public: State, Local or Tribal 

governments; Number of Respondents: 

56; Total Annual Responses: 56; Total 

Annual Hours: 336. (For policy 

questions regarding this collection 

contact Deborah McCleod at 410–786– 

0013. For all other issues call 410–786– 

1326.) 

4. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicaid Report 

on Payables and Receivables; Use: The 

Chief Financial Officers (CFO) Act of 

1990, as amended by the Government 

Management Reform Act (GMRA) of 

1994, requires government agencies to 

produce auditable financial statements. 

Because the Centers for Medicare & 

Medicaid Services (CMS) fulfills its 

mission through its contractors and the 

States; these entities are the primary 

source of information for the financial 

statements. There are three basic 

categories of data: expenses, payables, 

and receivables. The CMS–64 is used to 

collect data on Medicaid expenses. The 

CMS–R–199 collects Medicaid payable 

and receivable accounting data from the 

States.; Form Number: CMS–R–199 

(OMB#: 0938–0697); Frequency: 

Reporting—Annually; Affected Public: 

State, Local or Tribal governments; 

Number of Respondents: 56; Total 

Annual Responses: 56; Total Annual 

Hours: 336. (For policy questions 

regarding this collection contact 

Deborah McCleod at 410–786–0013. 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 September 15, 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, Room C4–26–05, 7500 

Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Dated: July 9, 2009. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. E9–17079 Filed 7–16–09; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

Periodically, the Health Resources 

and Services Administration (HRSA) 

publishes abstracts of information 

collection requests under review by the 

Office of Management and Budget 

(OMB), in compliance with the 

Paperwork Reduction Act of 1995 (44 

U.S.C. Chapter 35). To request a copy of 

the clearance requests submitted to 

OMB for review, e-mail 

paperwork@hrsa.gov or call the HRSA 

Reports Clearance Office on (301) 443– 

1129. 

The following request has been 

submitted to the Office of Management 

and Budget for review under the 

Paperwork Reduction Act of 1995: 

Proposed Project Title: Interim 

Evaluation of the Bright Futures for 

Women’s Health and Wellness 

(BFWHW) Initiative, Emotional 

Wellness Consumer Tools—NEW. 

Purpose: The purpose of this project 

is to design and implement a three-year 

interim evaluation to address initial 

outcomes for the BFWHW emotional 

wellness tools targeted to consumers. 

The project is funded by the Health 

Resources and Services Administration 

(HRSA), Office of Women’s Health 

(OWH). The evaluation will seek to 

determine (1) the acceptability of the 

tools by the target audiences, (2) 

strategies for ensuring their ongoing use, 

and (3) the outcomes associated with 

the use of these tools in three to four 

selected primary care sites. 

The evaluation team will work with 

HRSA OWH and an Expert Committee 

to identify the questions of interest for 

the evaluation plan and methodology. 

There will be two major components— 

a descriptive/process component 

focusing on the design and 

implementation of the program’s 

intervention and an impact component 

focusing on the preliminary outcomes of 

the intervention on the target audiences 

and their behavioral intentions. 

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