03-9115. Agency Information Collection Activities: Proposed Collection; 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: New collection; Title of Information Collection: Evaluation of the Illinois and Wisconsin State Pharmacy Assistance Waivers; Form No.: CMS-10087 (OMB# 0938-NEW); Use: CMS has implemented the Pharmacy Plus Initiative to grant waivers to states to provide pharmacy benefits to low-income elders with incomes too high to qualify for Medicaid. This study will evaluate the Pharmacy Plus programs initiated in the states of Illinois and Wisconsin using a variety of methods including a descriptive program evaluation, survey of participants, analyses of drug utilization and costs as well as the cost impact to the Medicare and Medicaid programs; Frequency: Other: one-time only; Affected Public: Individuals or Households; Number of Respondents: 2,200; Total Annual Responses: 2,200; Total Annual Hours: 550.

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Third Party Premium Billing Request; Form No.: CMS-2384; Use: The Third Party Premium Billing Request is used as an authorization to designate that a family member or other interested party receive the Medicare Premium Bill and pay it on behalf of a Medicare beneficiary. Frequency: On occasion; Affected Public: Individuals or households; Number of Respondents: 15,000; Total Annual Hours: 6,250.

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: TWWIIA Demonstration to Maintain Independence; Form No.: CMS-10006 (OMB# 0938-0799); Use: Section 204 of the Ticket to Work and Work Incentives Act provides for the establishment of grants for states that develop and implement demonstration programs designed to support working people with physical or mental impairments that without medical assistance will result in disability. State agencies will be applying for these grants; Frequency: Annually; Affected Public: State, Local, or Tribal government; Number of Respondents: 56; Total Annual Responses: 56; Total Annual Hours: 5,600.

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS's 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 60 days of this notice directly to the CMS Paperwork Clearance Officer designated at the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development and Issuances, Attention: Dawn Willinghan, Room: C5-14-03, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Dated: April 3, 2003.

Dawn Willinghan,

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