[Federal Register Volume 69, Number 237 (Friday, December 10, 2004)]
[Notices]
[Pages 71816-71817]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-27145]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-10115, CMS-10123 & 10124, CMS-R-211, CMS-
2552, and CMS-10048]


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: Extension of a currently 
approved collection; Title of Information Collection: Federal Funding 
of Emergency Health Services (Section 1011): Enrollment Application; 
Use: These information collections will allow hospitals and other 
providers to enroll to receive payment for Section 1011 claim 
submissions. Section 1011 provides $250 million per year for fiscal 
years 2005-2008 for payments to eligible providers for emergency health 
services provided to undocumented aliens and other specified aliens; 
Form Number: CMS-10115 (OMB: 0938-0929); Frequency: Other: as 
needed; Affected Public: Business or other for-profit, Not-for-profit 
institutions, and State, Local or Tribal Govt.; Number of Respondents: 
62,500; Total Annual Responses: 62,500; Total Annual Hours: 31,250.
    2. Type of Information Collection Request: New Collection; Title of 
Information Collection: Expedited Review Notices and Supporting 
Regulations contained in 42 CFR Sections 405.1200 and 405.1202; Use: 
These notices are used to inform beneficiaries that their provider 
services will end, and to provide beneficiaries who request an 
expedited determination with detailed information of why the services 
should end; Form Numbers: CMS-10123 & 10124 (OMB: 0938-NEW); 
Frequency: On occasion; Affected Public: Individuals or Households, 
Business or other for-profit, and Not-for-profit institutions; Number 
of Respondents: 4,200,000; Total Annual Responses: 4,200,000; Total 
Annual Hours: 379,400.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Model Application 
Template for State Child Health Plan Under Title XXI of the Social 
Security Act, State Children's Health Insurance Program, and Model 
Application Template and Instructions; Use: States are required to 
submit Title XXI plans and amendments for approval by the Secretary 
pursuant to section 2102 of the Social Security Act in order to receive 
funds for initiating and expanding health insurance coverage for 
uninsured children. The model application template is used to assist 
States in submitting a State Child Health Plan and amendments to that 
plan; Form Number: CMS-R-211 (OMB: 0938-0707); Frequency: 
Quarterly and Annually; Affected Public: State, Local or Tribal Govt.; 
Number of Respondents: 40; Total Annual Responses: 40; Total Annual 
Hours: 3,200.
    4. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Hospital and 
Health Care Complexes Cost Report and Supporting Regulations in 42 CFR 
413.20 and 413.24; Use: This form is completed by Hospitals and Health 
Care Complexes participating in the Medicare program. Hospitals and 
Health Care Complexes use this form to report the health care costs for 
services they provide. The information reported on this form is used by 
CMS to determine the amount of reimbursable costs for services rendered 
to Medicare beneficiaries. The revisions to this form contain the 
provisions for implementing section 422 of the MMA. Section 422 deals 
with the calculation of GME and IME payments for redistribution of

[[Page 71817]]

unused resident slots; Form Number: CMS-2552-96 (OMB 0938-
0050); Frequency: Annually; Affected Public: Business or other for-
profit, Not-for-profit institutions, and State, Local or Tribal 
Government; Number of Respondents: 6,111; Total Annual Responses: 
6,111; Total Annual Hours: 4,046,782.
    5. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Application 
Template for Health Insurance Flexibility and Accountability (HIFA) 
Section Demonstration Proposal; Use: The HIFA Initiative affords states 
an opportunity to expand coverage to the uninsured under Social 
Security Act Section 1115 demonstrations authority. States will be able 
to use Medicaid and State Child Health Insurance Program funds in 
concert with private insurance options to expand coverage to low-income 
uninsured individuals with a focus on those with income at or below 200 
percent of the Federal poverty level. The model demonstration 
application will facilitate State efforts in designing programs to 
cover the uninsured; Form Number: CMS-10048 (OMB 0938-0848); 
Frequency: Other: renewal every 5 yrs.; Affected Public: State, Local 
or Tribal Government; Number of Respondents: 10; Total Annual 
Responses: 9; Total Annual Hours: 42.
    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/regulations/pra/, 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 Reduction Act Reports Clearance Officer designated at 
the address below: CMS, Office of Strategic Operations and Regulatory 
Affairs, Division of Regulations Development, Attention: Melissa 
Musotto, Room C5-14-03, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850.

    Dated: December 3, 2004.
John P. Burke, III,
CMS Paperwork Reduction Act Reports Clearance Officer, Office of 
Strategic Operations and Regulatory Affairs, Regulations Development 
Group.
[FR Doc. 04-27145 Filed 12-9-04; 8:45 am]
BILLING CODE 4120-03-P