[Federal Register Volume 68, Number 26 (Friday, February 7, 2003)]
[Notices]
[Pages 6489-6490]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-2999]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifiers: CMS-R-289, CMS-10082, CMS 1763, and CMS-4040 and 
4040-SP]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare and Medicaid Services.
    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid 
Services (CMS) (formerly known as the Health Care Financing 
Administration (HCFA)), 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 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 
Lifestyle Modification Program Demonstration and Addendum; Form No.: 
CMS-R-289 (OMB 0938-0777); Use: This demonstration focuses on 
Medicare sponsored, lifestyle modification programs designed to 
reverse, reduce, or ameliorate the progression of cardiovascular 
disease (CAD) of Medicare beneficiaries at risk for invasive treatment 
procedures. This demonstration tests the feasibility and cost 
effectiveness of providing payment for cardiovascular lifestyle 
modification program services to Medicare beneficiaries; Frequency: On 
occasion, Weekly, Monthly, Quarterly; Affected Public: Individuals or 
Households, and Not-for-profit Institutions; Number of Respondents: 44; 
Total Annual Responses: 17,996; Total Annual Hours: 2,999.
    (2) Type of Information Collection Request: New collection; Title 
of Information Collection: Survey of States Performance Measurement 
Reporting Capability; Form No.: CMS-10082 (OMB 0938-NEW); Use: 
Because of the wide variability of Medicaid and SCHIP financing and 
service delivery approaches, there is little common ground from which 
to develop uniform reporting on performance measures by states. While 
CMS has decided on the first seven measures to be used, the ability of 
states to calculate those measures using HEDIS directly or HEDIS 
specifications (e.g., when calculating measures from fee-for-service 
claims data) is highly variable. Current efforts are focused on 
assessing the capability of each state to report on the selected 
measures and on helping states to make necessary adjustments in order 
to be able to report measures uniformly so that state-to-state 
comparisons can be made. To accomplish this, states will be requested 
to report available numerator and denominator data for the seven core 
HEDIS measures via a survey instrument created for this purpose. The 
data will be requested for each state's Medicaid and SCHIP programs by 
delivery system; Frequency: Once; Affected Public: State, local, and 
tribal government; Number of Respondents: 51; Total Annual Responses: 
51; Total Annual Hours: 2,360.
    (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; Form No.: CMS-1763 (OMB 0938-0025); Use: The CMS-
1763 is used by beneficiaries to request voluntary termination from 
Premium Hospital Insurance (premium-HI) and/or Supplementary Medicare 
Insurance (SMI); Frequency: One time only; Affected Public: Individuals 
or Households, Federal Government, State, local, and tribal government; 
Number of Respondents: 14,000; Total Annual Responses: 14,000; Total 
Annual Hours: 5,833.
    (4) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: Request 
for Enrollment in Supplemental Medicare Insurance and Supporting 
Regulations in 42 CR 407.10 and 401.11; Form No.: CMS-4040 and 4040-SP 
(OMB 0938-0245); Use: The CMS 4040 is used to establish 
entitlement to Supplemental Medical Insurance (Part B) by beneficiaries 
not eligible under Part A of the Title XVIII or Title II of the Social 
Security Act. The CMS-4040SP is also included in this renewal; 
Frequency: One time only; Affected Public:

[[Page 6490]]

Individuals or Households, Federal Government, State, local, and tribal 
government; Number of Respondents: 10,000; Total Annual Responses: 
10,000; Total Annual Hours: 2,500.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access CMS's 
Web Site address at http://cms.hhs.gov/regulations/pra/default.asp, or 
E-mail your request, including your address, phone number, OMB number, 
and CMS document identifier, to [email protected], or call the Reports 
Clearance Office on (410) 786-1326. Written comments and 
recommendations for the proposed information collections must be mailed 
within 60 days of this notice directly to the CMS Paperwork Clearance 
Officer designated at the following address: CMS, Office of Strategic 
Operations and Regulatory Affairs, Division of Regulations Development 
and Issuances, Attention: Dawn Willinghan, Room: C5-14-03, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850.

    Dated: January 30, 2003.
John P. Burke, III,
CMS Reports Clearance Officer, Office of Strategic Operations and 
Strategic Affairs, Division of Regulations Development and Issuances.
[FR Doc. 03-2999 Filed 2-6-03; 8:45 am]
BILLING CODE 4120-03-P