03-9548. 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 currently approved collection.

Title of Information Collection: Refinement of RHC Certification and QAPI and Supporting Regulations in 42 CFR 491.8 and 491.11.

Form No.: CMS-R-242 (OMB# 0938-0792).

Use: This collection contains information collection requirements concerning requests for additional waivers of staffing requirements and documentation of quality assessment and performance improvement programs.

Frequency: Annually.

Affected Public: Business or other for-profit.

Number of Respondents: 3,528.

Total Annual Responses: 3,573.

Total Annual Hours: 3,663.

2. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Request for Termination of Premium+Hospital and/or Supplementary Medical Insurance.

Form No.: CMS-1763 (OMB# 0938-0025).

Use: The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital Insurance (premium-HI) and/or Supplementary Medicare Insurance (SMI).

Frequency: One time only.

Affected Public: Individuals or Households, Federal Government, State, local, and tribal government.

Number of Respondents: 14,000.

Total Annual Responses: 14,000.

Total Annual Hours: 5,833.

3. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Request for Enrollment in Supplemental Medicare Insurance and Supporting Regulations in 42 CFR 407.10 and 401.11.

Form No.: CMS-4040 and 4040-SP (OMB# 0938-0245).

Use: The CMS 4040 is used to establish entitlement to Supplemental Medical Insurance (Part B) by beneficiaries not eligible under Part A of the Title XVIII or Title II of the Social Security Act. The CMS-4040SP is also included in this renewal.

Frequency: One time only.

Affected Public: Individuals or Households, Federal Government, State, local, and tribal government.

Number of Respondents: 10,000.

Total Annual Responses: 10,000.

Total Annual Hours: 2,500.

4. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Medicare Waiver Demonstration Application.

Form No.: CMS-10069 (OMB# 0938-0880).

Use: The Medicare Waiver Demonstration Application will be used to collect standard information needed to implement Congressionally mandated and administration high priority demonstrations. The application will be used to gather information about the characteristics of the applicant's organization, benefits, and services they propose to offer, success in operating the model, and evidence that the model is likely to be successful in the Medicare program. The standard application will be used for all waiver demonstrations and will reduce the burden on applicants, provide for consistent and timely information collections across demonstration, and provide a user-friendly format for respondents.

Frequency: On Occasion.

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

Number of Respondents: 75.

Total Annual Responses: 75.

Total Annual Hours: 1600.

5. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Conditions of Coverage of Suppliers of End Stage Renal Disease (ESRD).

Form No.: CMS-R-52 (OMB# 0938-0386).

Use: This package is needed to encourage proper distribution and effective utilization of ESRD treatment sources while maintaining and improving the efficient delivery of care by physicians and dialysis facilities.

Frequency: Annually.

Affected Public: Business or other for-profit and Federal Government.

Number of Respondents: 4,297.

Total Annual Responses: 4,297.

Total Annual Hours: 148,785.

6. Type of Information Collection Request: Revision of a currently approved collection.

Title of Information Collection: Information Collection Requirements in the Hospice Conditions Coverage. The following regulations are affected: 42 CFR 418.22; 418.24; 418.28; 418.56(b), (e)(1), (e)(3); 418.58; 418.70(e); 418.83; 418.96(b); and 418.100(b).

Form No.: CMS-R-30 (OMB# 0938-0302).

Use: Establishes standards for hospices that wish to participate in the Medicare program. The regulations establish standards for eligibility, reimbursement standards and procedure, and delineate conditions that hospices must meet to be approved for participation in Medicare.

Frequency: On occasion.

Affected Public: Business or other for-profit.

Number of Respondents: 2,316.

Total Annual Responses: 2,316.

Total Annual Hours: 5,981,427.

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: April 10, 2003.

Dawn Willinghan,

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