03-28710. Agency Information Collection Activities: Submission for OMB Review; Comment Request

Agency: Centers for Medicare and Medicaid Services, HHS. 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: Qualification Application: Medicare+Choice Application for HMOs, PPOs, and State Licensed PSOs; Medicare+Choice Application for Federally Waived PSOs; Medicare+Choice Application for Medicare Savings Account Entities; Medicare+Choice Application for Private Fee-for-Service Plans; Form No.: CMS-901 (OMB# 0938-0470); Use: Prepaid health plans must meet certain regulatory requirements to be federally qualified health maintenance organizations or to enter into a contract with CMS to provide health benefits to Medicare beneficiaries. The application is the collection form to obtain the information from a health plan that will allow CMS staff to determine compliance with the regulations; Frequency: Other: One-time submission; Affected Public: Business or other for-profit, Not-for-profit institutions, State, Local or Tribal Government; Number of Respondents: 55; Total Annual Responses: 55; Total Annual Hours: 5,500.

2. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133; Form No.: CMS-2744 (OMB# 0938-0447); Use: The ESRD 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; Frequency: Annually; Affected Public: Business or other for-profit, and Not-for-profit institutions; Number of Respondents: 4,360; Total Annual Responses: 4,360; Total Annual Hours: 34,880.

3. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5, 5b; 20 CFR Parts 401, 422E; Form No.: CMS-2746 (OMB# 0938-0448); Use: The ESRD Death Notification is to be completed upon the death of ESRD patients. Its primary purpose is to collect fact and cause of death. Reports of deaths are used to show cause of death and demographic characteristics of these patients; Frequency: Other: One-time (patient death); Affected Public: Business or other for-profit, Not-for-profit institutions, and Federal Government; Number of Respondents: 4,360; Total Annual Responses: 69,760; Total Annual Hours: 34,880.

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://cms.hhs.gov/​regulations/​pra/​default.asp,, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to [e-mail], or call the Reports Clearance Office on [phone]. Written comments and recommendations for the proposed information collections must be mailed within 30 days of this notice directly to the OMB desk officer: OMB Human Resources and Housing Branch, Attention: Brenda Aguilar, New Executive Office Building, Room 10235, Washington, DC 20503.

Dated: November 7, 2003.

Julie Brown,

CMS Reports Clearance Officer, Office of Strategic Operations and Strategic Affairs, Division of Regulations Development and Issuances.