[Federal Register Volume 74, Number 242 (Friday, December 18, 2009)]
[Notices]
[Pages 67227-67229]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-30176]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-3070, CMS-576/576A, CMS-416, CMS-10028 and 
CMS-2744, CMS-10088, CMS-R-142, CMS-10197 and CMS-10304]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare & Medicaid Services.

    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: Intermediate Care 
Facility (ICF) for the Mentally Retarded (MR) or Persons with Related 
Conditions Survey Report Form and Supporting Regulations at 42 CFR 
442.30, 483.410, 483.420, 483.440, 483.450 and 483.460; Use: This 
survey form is needed to ensure ICF/MR provider and client 
characteristics are available and updated annually for the federal 
government's Online Survey Certification and Reporting (OSCAR) system. 
It is required for the provider to fill out at the time of the annual 
recertification or initial certification survey conducted by the State 
Medicaid agency. The team leader for the state survey team must review 
and approve the completed form before completion of the survey. The 
State Medicaid survey agency is responsible for transferring the 3070 
information into OSCAR. Form Number: CMS-3070 (OMB: 0938-
0062); Frequency: Reporting--Yearly; Affected Public: Private Sector: 
Business or other for-profits and Not-for-profit institutions; Number 
of Respondents: 6,437; Total Annual Responses: 6,437; Total Annual 
Hours: 19,311. (For policy questions regarding this collection contact 
Kelley Tinsley at 410-786-6664. For all other issues call 410-786-
1326.)
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Organ Procurement 
Organization's (OPO's) Health Insurance Benefits Agreement and 
Supporting Regulations at 42 CFR 486.301-486.348; Use: The information 
provided on this form serves as a basis for continuing the agreements 
with CMS and the 580 OPOs for participation in the Medicare and 
Medicaid programs for reimbursement of service. Form Number: CMS-576/
576A (OMB: 0938-0512); Frequency: Reporting--Occasionally; 
Affected Public: Private Sector: Business or other for-profits and Not-
for-profit institutions; Number of Respondents: 58; Total Annual 
Responses: 58; Total Annual Hours: 116. (For policy questions regarding 
this collection contact Michele Walton at 410-786-3353. For all other 
issues call 410-786-1326.)
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Annual Early and 
Periodic Screening, Diagnostic and Treatment (EPSDT) Services 
Participation Report; Form Number: CMS-416 (OMB: 0938-0354); 
Use: States are required to submit an annual report on the provision of 
EPSDT services pursuant to section 1902(a)(43)(D) of the Social 
Security Act. These reports provide CMS with data necessary to assess 
the effectiveness of State EPSDT programs, to determine a State's 
results in achieving its participation goal and to respond to 
inquiries. Respondents are State Medicaid Agencies. The data is due 
April 1 of every year so States need to have the form and instructions 
as soon as possible in order to report timely. Frequency: Yearly; 
Affected Public: State, Tribal and Local governments; Number of 
Respondents: 56; Total Annual Responses: 56; Total Annual Hours: 504. 
(For policy questions regarding this collection contact Cindy Ruff at 
410-786-5916. For all other issues call 410-786-1326.)
    4. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: State Health 
Insurance Assistance Program (SHIP) Client Contact Form, Public and 
Media Form, and Resource Report Form; Form Number: CMS-10028 
(OMB: 0938-0850); Use: The current Client Contact form, Public 
and Media Activity Report form, and Resource Report have been used to 
collect data to evaluate program effectiveness and improvement. In 
addition, the 2007-2009 State Health Insurance Program (SHIP) 
Performance Assessment Workgroup (comprised of SHIP Directors and 
representatives from external organizations such as the Administration 
on Aging), in a report to CMS, recommended that changes be made to the 
forms in order to enhance the ability to measure performance and 
program evaluation for each SHIP; add additional data collection 
elements as requested by Congress and SHIPs (Limited English 
Proficiency and Dual Mentally Disabled); and reduce the burden of data 
submission by counselor as a result of the ability to pre-populate 
certain data cells. The information collected is used to fulfill the 
reporting requirements described in Section 4360(f) of OBRA 1990. Also, 
the data will be accumulated and analyzed to

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measure SHIP performance in order to determine whether and to what 
extent the SHIPs have met the goals of improved CMS customer service to 
beneficiaries and better understanding by beneficiaries of their health 
insurance options. Further, the information will be used in the 
administration of the grants, to measure performance and appropriate 
use of the funds by the state grantees, to identify gaps in services 
and technical support needed by SHIPs, and to identify and share best 
practices. Frequency: Yearly; Affected Public: State, Tribal and Local 
governments; Number of Respondents: 20,778; Total Annual Responses: 
1,672,454; Total Annual Hours: 139,475. (For policy questions regarding 
this collection contact Barbara Childers at 410-786-7610. For all other 
issues call 410-786-1326.)
    5. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: End Stage Renal 
Disease (ESRD) Medical Information Facility Survey; Form Number: CMS-
2744 (OMB: 0938-0447); Use: The End Stage Renal Disease (ESRD) 
Medical Information Facility Survey form (CMS-2744) is completed 
annually by Medicare-approved providers of dialysis and transplant 
services. The CMS-2744 is designed to collect information concerning 
treatment trends, utilization of services and patterns of practice in 
treating ESRD patients. The information is used to assess and evaluate 
the local, regional and national levels of medical and social impact of 
ESRD care and is used extensively by researchers and suppliers of 
services for trend analysis. The information is available on the CMS 
Dialysis Facility Compare Web site and will enable patients to make 
informed decisions about their care by comparing dialysis facilities in 
their area. Frequency: Yearly; Affected Public: Business or other for-
profit, Not-for-profit institutions; Number of Respondents: 5,465; 
Total Annual Responses: 5,465; Total Annual Hours: 43,720. (For policy 
questions regarding this collection contact Connie Cole at 410-786-
0257. For all other issues call 410-786-1326.)
    6. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Notification of 
Fiscal Intermediaries and CMS of co-located Medicare providers and 
Supporting Regulations in 42 CFR 412.22 and 412.533; Use: Many long-
term care hospitals (LTCHs) are co-located with other Medicare 
providers (acute care hospitals, IRFs, SNFs, psychiatric facilities), 
which leads to potential gaming of the Medicare system based on patient 
shifting. CMS is requiring LTCHs to notify fiscal intermediaries K 
(FIs), Medicare Administrative Contractors (MACs) and CMS of co-located 
providers and establish policies to limit payment abuse that will be 
based on FIs tracking patient movement among these co-located 
providers. Form Number: CMS-10088 (OMB: 0938-0897); Frequency: 
Occasionally; Affected Public: Private Sector, Business or other for-
profits and Not-for-profit institutions; Number of Respondents: 25; 
Total Annual Responses: 25; Total Annual Hours: 6.25. (For policy 
questions regarding this collection contact Judith Richter at 410-786-
2590. For all other issues call 410-786-1326.)
    7. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Examination and 
Treatment for Emergency Medical Conditions and Women in Labor (EMTALA), 
42 CFR 482.12, 488.18, 489.20, and 489.24; Use: This collection 
contains the requirements for hospitals in effort to prevent them from 
inappropriately transferring individuals with emergency medical 
conditions, as mandated by Congress. CMS uses this information to help 
assure compliance with this mandate. This information is not contained 
elsewhere in regulations. Form Number: CMS-R-142 (OMB: 0938-
0667); Frequency: Daily; Affected Public: Individuals or households; 
Private Sector; Number of Respondents: 6,149; Total Annual Responses: 
6,149; Total Annual Hours: 1. (For policy questions regarding this 
collection contact Renate Rockwell at 410-786-4645. For all other 
issues call 410-786-1326.)
    8. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Evaluation of the 
Medicare National Competitive Bidding Program for DME; Use: Data 
collection materials consisting of beneficiary surveys and interview/
discussion group guides are necessary to conduct the congressionally 
mandated evaluation of the Medicare National Competitive Bidding 
Program. Medicare Modernization (MMA) Section 303(d) requires a Report 
to Congress on the program, covering program savings, reductions in 
cost sharing, impacts on access to and quality of affected goods and 
services, and beneficiary satisfaction. This project's purpose is to 
provide information for this Report to Congress. Due to substantial 
legislative and regulatory delays in program implementation, the Report 
to Congress in 2011 will be released just as the program is being 
implemented, and before the evaluation is complete. This project will 
continue after the Report to Congress, to evaluate the impact of the 
program on beneficiaries, on Medicare costs, and on changes in the 
Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies 
(DMEPOS) market. Form Number: CMS-10197 (OMB: 0938-1015); 
Frequency: Occasionally; Affected Public: Individuals or households, 
Private Sector, Business or other for-profits, not-for-profit 
institutions, and Federal Government; Number of Respondents: 8,466; 
Total Annual Responses: 8,466; Total Annual Hours: 4,338. (For policy 
questions regarding this collection contact Ann Meadow at 410-786-6602. 
For all other issues call 410-786-1326.)
    9. Type of Information Collection Request: New collection; Title of 
Information Collection: Information Collection Requirements and 
Supporting Information for Chronic Kidney Disease Surveys under the 9th 
Scope of Work; Form Number: CMS-10304 (OMB: 0938-New); Use: 
The Centers for Medicare & Medicaid Services (CMS) and the U.S. 
Department of Health and Human Services (DHHS) are requesting OMB 
clearance for the Chronic Kidney Disease (CKD) Partner Survey and the 
Chronic Kidney Disease (CKD) Provider Survey. The Prevention CKD Theme 
is a component of the Prevention Theme of the Quality Improvement 
Organization (QIO) Program's 9th Scope of Work (SOW). The statutory 
authority for this scope of work is found in Part B of Title XI of the 
Social Security Act (the Act) as amended by the Peer Review Improvement 
Act of 1982. The Act established the Utilization and Quality Control 
Peer Review Organization Program, now known as the Quality Improvement 
Organization (QIO) Program.
    The goal of the Prevention CKD Theme is to detect the incidence, 
decrease the progression of CKD, and improve care among Medicare 
beneficiaries through provider adoption of timely and effective quality 
of care interventions; participation in quality incentive initiatives; 
beneficiary education; and key linkages and collaborations for system 
change at the state and local level. In addition to improving the 
quality of care for the elderly and frail-elderly, this Theme aims to 
reduce the rate of Medicare entitlement by disability through the delay 
and prevention of end-stage renal disease (ESRD); thus resulting in 
higher

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quality care and significant savings to the Medicare Trust Fund.
    The CKD Partner Survey constitutes a new information collection to 
be used by CMS to obtain information on how QIO collaboration with 
partners facilitates systems change within the QIO's respective state. 
The CKD Partner Survey will be a census administered to 350 
collaborative partners in the 9th SOW. The CKD Partner Survey will be 
administered via telephone. Responses will be entered into a pre-
programmed Computer-Assisted Telephone Interviewing (CATI) interface. 
The results of the survey shall be used for inpatient quality 
indicators (IQI) by the QIO. CMS will also use the results to assess 
how partner organizations and their perspective of the QIO's role are 
implementing system change.
    Similarly, the CKD Provider Survey constitutes a new information 
collection to be used by CMS to obtain information on how QIO 
collaboration with physician practices facilitates systems change 
within the QIO's respective state. The CKD Provider Survey will be 
administered via telephone and the Web. Responses collected by phone 
will be entered into a pre-programmed Computer-Assisted Telephone 
Interviewing (CATI) interface. Responses collected by Web will be 
housed on a secure server and database. The results of the survey shall 
be used for inpatient quality indicators (IQI) by the QIO. CMS will 
also use the results to assess how physicians' practices and their 
perspective of the QIO's role are implementing system change. 
Frequency: Yearly; Affected Public: Private Sector--Business or other 
for-profits and Not-for profit institutions; Number of Respondents: 
1,350; Total Annual Responses: 1,350; Total Annual Hours: 337.5. (For 
policy questions regarding this collection contact Robert Kambic at 
410-786-1515. 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 [email protected], 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 February 16, 2010:
    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: December 11, 2009.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. E9-30176 Filed 12-17-09; 8:45 am]
BILLING CODE 4120-01-P