Agency Information Collection Activities: Proposed Collection; Comment Request, 67227-67229 [E9-30176]
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Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices
inspection at the Federal Reserve Bank
indicated. The applications also will be
available for inspection at the offices of
the Board of Governors. Interested
persons may express their views in
writing on the standards enumerated in
the BHC Act (12 U.S.C. 1842(c)). If the
proposal also involves the acquisition of
a nonbanking company, the review also
includes whether the acquisition of the
nonbanking company complies with the
standards in section 4 of the BHC Act
(12 U.S.C. 1843). Unless otherwise
noted, nonbanking activities will be
conducted throughout the United States.
Additional information on all bank
holding companies may be obtained
from the National Information Center
website at www.ffiec.gov/nic/.
Unless otherwise noted, comments
regarding each of these applications
must be received at the Reserve Bank
indicated or the offices of the Board of
Governors not later than January 14,
2010.
A. Federal Reserve Bank of Kansas
City (Dennis Denney, Assistant Vice
President) 1 Memorial Drive, Kansas
City, Missouri 64198–0001:
1. GFP Financial Services Company,
Tulsa, Oklahoma; to become a bank
holding company by acquiring 65.04
percent of the voting shares of First
Pryor Bancorp, Inc., and First Pryority
Bank, both in Pryor, Oklahoma.
Board of Governors of the Federal Reserve
System, December 15, 2009.
Robert deV. Frierson,
Deputy Secretary of the Board.
[FR Doc. E9–30100 Filed 12–17–09; 8:45 am]
BILLING CODE 6210–01–S
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]
sroberts on DSKD5P82C1PROD with NOTICES
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
VerDate Nov<24>2008
17:33 Dec 17, 2009
Jkt 220001
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 forprofits 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
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67227
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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67228
Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices
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-forprofit 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 colocated Medicare providers and
Supporting Regulations in 42 CFR
412.22 and 412.533; Use: Many longterm care hospitals (LTCHs) are colocated with other Medicare providers
(acute care hospitals, IRFs, SNFs,
psychiatric facilities), which leads to
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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 colocated 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
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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 forprofits, 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
E:\FR\FM\18DEN1.SGM
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Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices
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 forprofits 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 https://www.cms.hhs.gov/
PaperworkReductionActof1995, or
e-mail 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 February 16, 2010:
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17:33 Dec 17, 2009
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1. Electronically. You may submit
your comments electronically to https://
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
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–10299, CMS–
10300 and CMS–10294]
Agency Information Collection
Activities: Submission for OMB
Review; 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), 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 function;
(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: New Collection; Title of
Information Collection: State Plan
Amendment Template for the Option to
Cover Certain Children and Pregnant
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Sfmt 4703
67229
Women Lawfully residing in U.S.; Use:
This new option for State Medicaid and
Children Health Insurance Programs
(CHIP) was provided by section 214 of
the Children’s Health Insurance
Program Reauthorization Act of 2009,
Public Law 111–3, which amends
section 1902 of the Social Security Act.
To select this option, a State Medicaid
or CHIP agency will complete a
template page and submit it for approval
as part of their State Plan. Form
Number: CMS–10299 (OMB#: 0938–
NEW); Frequency: Reporting—Once and
occasionally; Affected Public: State,
Local, or Tribal Governments; Number
of Respondents: 51; Total Annual
Responses: 51; Total Annual Hours: 51.
(For policy questions regarding this
collection contact Bob Tomlinson at
410–786–5907. For all other issues call
410–786–1326.)
2. Type of Information Collection
Request: New collection; Title of
Information Collection: State Plan
Amendment Templates for Additional
State Plan Option for Providing
Premium Assistance under Title XIX
and XXI; Use: Section 301 of the
Children’s Health Insurance Program
Reauthorization Act of 2009 (CHIPRA),
Public Law 111–3, adds Section
2105(c)(10) of the Social Security Act
effective April 1, 2009, to offer States a
new option to provide premium
assistance subsidies to enroll targeted
low-income individuals under age 19,
and their parents in qualified employersponsored coverage. To elect this
option, a State Children’s Health
Insurance Program agency will complete
the template pages and submit it for
approval as part of a State plan
amendment. Form Number: CMS–10300
(OMB#: 0938–New); Frequency:
Reporting—Once and On occasion;
Affected Public: State, Local or Tribal
Government; Number of Respondents:
51; Total Annual Responses: 51; Total
Annual Hours: 255. (For policy
questions regarding this collection
contact Stacey Green at 410–786–6102.
For all other issues call 410–786–1326.)
3. Type of Information Collection
Request: New collection; Title of
Information Collection: Program
Evaluation of the Eighth and Ninth
Scope of Work Quality Improvement
Organization Program; Use: The
statutory authority for the Quality
Improvement Organization (QIO)
Program is found in Part B of Title XI
of the Social Security Act, as amended
by the Peer Review Improvement Act of
1982. The Social Security Act
established the Utilization and Quality
Control Peer Review Organization
Program, now known as the QIO
Program. The statutory mission of the
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]]>Agencies
[Federal Register Volume 74, Number 242 (Friday, December 18, 2009)]
[Notices]
[Pages 67227-67229]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-30176]
=======================================================================
-----------------------------------------------------------------------
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
[[Page 67228]]
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
[[Page 67229]]
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 https://www.cms.hhs.gov/PaperworkReductionActof1995, or e-
mail 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 February 16, 2010:
1. Electronically. You may submit your comments electronically to
https://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
