03-29821. 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: Extension of a previously approved collection.

Title of Information Collection: Intermediate Care Facility for the Mentally Retarded or Persons with Related Conditions ICF/MR Survey Report Form (3070G-I) and Supporting Regulations at 42 CFR 442.30, 483.410, 483.420, 483.440, 483.450, and 483.460.

Form No.: CMS-3070 (0938-0062).

Use: The survey forms are needed to ensure provider compliance. In order to participate in the Medicaid program as an ICF/MR, a provider must meet Federal standards. The survey report form is used to record providers' level of compliance with the individual standard and report it to the Federal government. The collection includes the information collection requirements that ICF/MRs must meet.

Frequency: Annually.

Affected Public: Business or other for-profit, Not-for-profit institutions.

Number of Respondents: 6,763.

Total Annual Responses: 177,721,815.

Total Annual Hours: 6,841,538.

2. Type of Information Collection Request: New Collection.

Title of Information Collection: “Detailed Explanation of Non-Coverage” 42 CFR 422.626(e)(1), and “Important Message of Non-Coverage” 42 CFR 625(b)(1).

Form No.: CMS-10095 (OMB# 0938-NEW).

Use: Pursuant of 42 CFR 422.624(b)(1), providers in skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities must deliver to M+C enrollees a 2-day advance notice of termination of services. Per requirements at 42 CFR 422.626(e)(1), M+C organizations must deliver detailed notices to the QIO and enrollees upon request for appeal of the termination of services. These notices fulfill the regulatory requirement.

Frequency: Other: distribution.

Affected Public: Business or other-for-profit, Not-for-profit institutions, Federal Government, and Individuals or Households.

Number of Respondents: 22,247.

Total Annual Responses: 612,000.

Total Annual Hours: 68,000.

3. Type of Information Collection Request: New Collection.

Title of Information Collection: Medicare Health Survey (MHS).

Form No.: CMS-10096 (OMB# 0938-NEW).

Use: The Centers for Medicare and Medicaid Services has developed a survey, the Medicare Health Survey, that is similar to the Health Outcomes Survey (HOS). The main purpose of the MHS is to collect information that may be used to adjust Medicare payment. This approach has been tested for PACE (as mandated by BBA) and other organizations that serve frail populations and frailty adjusted payments will be made to PACE and certain demonstrations starting in 2004. CMS is currently investigating the feasibility of applying frailty adjustment to the M+C program in the future. To conduct the necessary research, CMS needs functional impairment information for a national sample of FFS beneficiaries. The information will be used for two purposes; to develop appropriate adjustments to the ratebook for levels of functional impairment, and to recalibrate the frailty payment model using FFS data. Adjusting the ratebook is necessary to ensure accurate payment while recalibration of the frailty model based on the MHS will properly align the calibration of the model and the data collection method, thereby avoiding payment error associated with the mode of administration issues.

Frequency: Annually.

Affected Public: Individuals or Households.

Number of Respondents: 50,000.

Total Annual Responses: 40,000.

Total Annual Hours: 6,667.

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 20, 2003.

Melissa Musotto,

Acting Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, Office of Strategic Operations and Strategic Affairs, Division of Regulations Development and Issuances.