Agency Information Collection Activities: Submission for OMB Review; Comment Request

AGENCY:

Centers for Medicare & 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 & 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 Pre-print for Integrated Medicare and Medicaid Programs; Use: Information submitted via the State Plan Amendment (SPA) pre-print will be used by CMS Central and Regional Offices to analyze a State's proposal to implement integrated Medicare and Medicaid programs. The pre-print is an optional document for use by States to highlight the arrangements between a State and Medicare Advantage Special Needs Plans that are also providing Medicaid services. State Medicaid Agencies will complete the SPA pre-print and submit it to CMS for a comprehensive analysis. The pre-print provides the opportunity for States to confirm that their integrated care model complies with both federal statutory and regulatory requirements. The pre-print contains assurances, check-off items, and areas for States to describe policies and procedures for subjects such as enrollment, marketing and quality assurance. Form Numbers: CMS-10251 (OMB#: 0938-NEW); Frequency: Reporting—Once; Affected Public: State, Local, or Tribal Governments; Number of Respondents: 56; Total Annual Responses: 30; Total Annual Hours: 600.

2. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: 1932 State Plan Amendment Template, State Plan Requirements and Supporting Regulations in 42 CFR 438.50; Form No.: CMS-10120 (OMB#: 0938-0933); Use: The State Medicaid Agencies will complete the template. CMS will review the information to determine if the State has met all the requirements under Section 1932(l)(1)(A) of the Social Security Act and 42 CFR 438.50. Once all requirements are met, the State will be allowed to enroll Medicaid beneficiaries on a mandatory basis into managed care entities without section 1115 or 1915(b) waiver authority; Frequency: On occasion; Affected Public: State, local, or tribal government; Number of Respondents: 56; Total Annual Responses: 10; Total Annual Hours: 100.

3. Type of Information Collection Request: New Collection; Title of Information Collection: Annual State Report and Annual State Performance Rankings; Use: The Deficit Reduction Act of 2005 (DRA) requires CMS to contract with a vendor to conduct a monthly national survey of retail prescription drug prices and to report the prices to the States. These national average prices will be used as a benchmark by the States for the management of their prescription drug programs. The law also requires that States report their drug utilization rates for non-innovator multiple source drugs, their payment rates under their State plan, and their dispensing fees. A template will be used to facilitate data collection. The States' rankings are to be presented to the Congress and the States. Form Number: CMS-10241 (OMB#: 0938-NEW); Frequency: Reporting—Yearly; Affected Public: States, Local or Tribal Governments; Number of Respondents: 51; Total Annual Responses: 51; Total Annual Hours: 765.

4. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: Health Insurance Benefit Agreement, Ambulatory Surgical Centers (ASC) Request for Certification in the Medicare Program, ASC Survey Report Form and ASC Conditions of Coverage; Use: The Health Insurance Benefit Agreement is utilized for the purpose of establishing for payment under Title XVIII of the Social Security Act. The ASC Request for Certification form is utilized as an application for facilities wishing to participate in the Medicare program as an ASC. This form initiates the process of obtaining a decision as to whether the conditions for coverage are met. It also promotes data retrieval from the Online Data Input Edit (ODIE system, a subsystem of the Online Survey Certification and Report (OSCAR) system by CMS Regional Offices (ROs). The ASC Report Form is an instrument used by the State survey agency to record data collection in order to determine supplier compliance with individual conditions for coverage and report it to the Federal Government. The form is primarily a coding worksheet designed to facilitate data reduction and retrieval into the ODIE/OSCAR system at the CMS ROs. This form includes basic information on compliance (i.e., met, not met and explanatory statements) and does not require any descriptive information regarding the survey activity itself. Form Numbers: CMS-370, 377, 378 (OMB#: 0938-0266); Frequency: Reporting—Occasionally (initially and then every 3 years); Affected Public: States, Local or Tribal Governments; Number of Respondents: 5123; Total Annual Responses: 1707; Total Annual Hours: 2,787.

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://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.

To be assured consideration, comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on January 7, 2008.

OMB Human Resources and Housing Branch, Attention: Katherine Astrich, New Executive Office Building, Room 10235, Washington, DC 20503, Fax Number: (202) 395-6974.