[Federal Register Volume 68, Number 216 (Friday, November 7, 2003)]
[Notices]
[Pages 63104-63106]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-28090]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-565, CMS-9044, CMS-P-0015A, CMS-1491, CMS-R-
13, CMS-R-246, CMS-R-204, CMS-304 and 304a]


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

[[Page 63105]]

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: Extension of a currently 
approved collection; Title of Information Collection: Medicare 
Qualification Statement for Federal Employees and Supporting 
Regulations in 42 CFR 406.15; Form No.: CMS-565 (OMB 0938-
0501); Use: The CMS-565 is completed by individuals filing for hospital 
insurance ([HI] Part A) benefits based upon their federal employment. 
This information is needed to determine if SSA/CMS can use (deem) 
federal employment prior to 1983 to provide quarters of coverage so the 
individual can qualify for free hospital insurance.; Frequency: Other: 
One-time-only; Affected Public: Individuals or Households, Federal 
Government, State, Local, or Tribal Government; Number of Respondents: 
4,300; Total Annual Responses: 4,300; Total Annual Hours: 717.
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Provider 
Reimbursement Manual, Part 1--Chapter 27, Sections 2721, 2722 and 2725, 
Request for Exception to End Stage Renal Disease Composite Rates and 
Supporting Regulations in 42 CFR 413.170 and 413.184; Form No.: CMS-
9044 (OMB 0938-0296); Use: This information collection 
describes the information End Stage Renal Disease facilities must 
submit in justifying an exception request to their composite rate for 
outpatient dialysis services; Frequency: On occasion; Affected Public: 
Business or other for-profit, Not-for-profit institutions, and Federal 
Government; Number of Respondents: 125; Total Annual Responses: 125; 
Total Annual Hours: 6,000.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicare Current 
Beneficiary Survey (MCBS): Rounds 38-46; Form No.: CMS-P-0015A 
(OMB 0938-0568); Use: The MCBS is a continuous, multipurpose 
survey of a nationally representative sample of aged and disabled 
persons enrolled in Medicare. The survey provides a comprehensive 
source of information on beneficiary characteristics, needs, 
utilization, and satisfaction with Medicare-related activities; 
Frequency: Other: 3 times a year; Affected Public: Individuals or 
Households, Business or other for-profit, and Not-for-profit 
institutions; Number of Respondents: 16,500; Total Annual Responses: 
49,500; Total Annual Hours: 50,325.
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Medicare Payment--Ambulance and Supporting Regulations in 42 CFR 
Sections 410.1, 410.40, 424.124, 414.601, 414.605, 414.610, 414.611, 
414.615, 414.620, and 414.625; Form No.: CMS-1491 (OMB 0938-
0042); Use: This paper form is completed on an occasion basis by 
beneficiaries and/or ambulance suppliers. Also, it is submitted to a 
Medicare carrier to request payment for ambulance services; Frequency: 
On occasion; Affected Public: Business or other for-profit, Individuals 
or Households, and Not-for-profit institutions; Number of Respondents: 
9,301,183; Total Annual Responses: 9,301,183; Total Annual Hours: 
390,493.
    5. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Conditions of 
Coverage for Organ Procurement Organizations (OPOs) and Supporting 
Regulations in 42 CFR, Sections 486.304, 486.306, 486.307, 486.310, 
486.316, 486.318, and 486.325; Form No.: CMS-R-13 (OMB 0938-
0688); Use: Organ Procurement Organizations are required to submit 
accurate data to CMS concerning population and information on donors 
and organs on an annual basis in order to assure maximum effectiveness 
in the procurement and distribution of organs; Frequency: Annually; 
Affected Public: Not-for-profit institutions; Number of Respondents: 
59; Total Annual Responses: 59; Total Annual Hours: 59,000.
    6. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicare Consumer 
Assessment of Health Plan Survey--Medicare + Choice (CAHPS-M+C); Form 
No.: CMS-R-246(OMB 0938-0732); Use: Under the Balanced Budget 
Act of 1997, CMS is required to provide general and plan comparative 
information to beneficiaries that will help them make more informed 
health plan choices. A CAHPS fee-for-service survey is needed to 
provide information comparable to those data collected from the CAHPS 
managed care survey; Frequency: Annually; Affected Public: Individuals 
or Households; Number of Respondents: 168,000; Total Annual Responses: 
168,000; Total Annual Hours: 55,450.
    7. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Data Collection 
for the Second Generation Social Health Maintenance Organization 
Demonstration; Form No.: CMS-R-204 (OMB 0938-0709; Use: The 
Centers for Medicare and Medicaid Services will continue to use the 
data collected under this effort to support the operational needs of 
the congressionally mandated and administratively extended Second 
Generation of the Social Health Maintenance Organization 
Demonstration.; Frequency: Annually; Affected Public: Individuals or 
Households; Number of Respondents: 15,000; Total Annual Responses: 
15,000; Total Annual Hours: 4,950.
    8. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicaid Drug 
Rebate; Form No.: CMS-304 and 304a (0938-0676); Use: Section 1927 of 
the Social Security Act requires State Medicaid agencies to report to 
drug manufacturers and CMS on the drug utilization for their State and 
the amount of rebate to be paid by the manufacturer; Frequency: 
Quarterly; Affected Public: State, local, or tribal government; Number 
of Respondents: 51; Total Annual Responses: 204; Total Annual Hours: 
6,125.
    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

[[Page 63106]]

Regulatory Affairs, Division of Regulations Development and Issuances, 
Attention: Melissa Musotto, Room C5-14-03, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850.

    Dated: October 30, 2003.
Julie Brown,
CMS Reports Clearance Officer, Office of Strategic Operations and 
Strategic Affairs, Division of Regulations Development and Issuances.
[FR Doc. 03-28090 Filed 11-6-03; 8:45 am]
BILLING CODE 4120-03-P