Agency Information Collection Activities: Proposed Collection; Comment Request

AGENCY:

Health Care Financing Administration, HHS.

In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, 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: Request for Medicare Payment —Ambulance and Supporting Regulations in 42 CFR Section 410.40 and 424.124;

Form No.: HCFA-1491 (OMB# 0938-0042);

Use: This form is used by physicians, suppliers, and beneficiaries to request payment of Part B Medicare services. It is used to apply for reimbursement for ambulance services.

Frequency: On occasion;

Affected Public: Business or other for-profit, Individuals or households, and Not-for-profit Institutions;

Number of Respondents: 9,301,183;

Total Annual Responses: 9,301,183;

Total Annual Hours: 390,418.

(2) Type of Information Collection Request: Extension of a currently approved collection;

Title of Information Collection: ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330;

Form No.: HCFA-382 (OMB# 0938-0372);

Use: ESRD facilities have each new home dialysis patient select one of two methods to handle Medicare reimbursement. The intermediaries pay for the beneficiaries selecting Method I and the carriers pay for the beneficiaries selecting Method II. This system was developed to avoid duplicate billing by both intermediaries and carriers.

Frequency: Other (One time only);

Affected Public: Individuals or Households, Business or other for-profit, and Not-for-profit institutions;

Number of Respondents: 8,600;

Total Annual Responses: 8,600;

Total Annual Hours: 717.

(3) Type of Information Collection Request: Revision of a currently approved collection;

Title of Information Collection: Evaluation of the State Medicaid Reform Demonstrations and Evaluation of the Medicaid Health Reform Demonstrations;

Form No.: HCFA-R-207 (OMB# 0938-0708);

Use: These evaluations investigate health care reform in ten states that have implemented demonstration programs using Section 1115 waivers. The surveys gather information to answer questions regarding access to health care, quality of care delivered, satisfaction with health services, and the use and cost of health services. During the extended period of authorization, the surveys will be administered to Medicaid eligibles, both demonstration participants and comparison group non-participants.

Frequency: Other: One-time;

Affected Public: Individuals or Households;

Number of Respondents: 5,050;

Total Annual Responses: 5,050;

Total Annual Hours: 2,746.

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access HCFA's Web Site address at http://www.hcfa.gov/regs/prdact95.htm,, or E-mail your request, including your address, phone number, OMB number, and HCFA document identifier, to Paperwork@hcfa.gov, or call the Reports Clearance Office on (410) 786-1326. Written comments and recommendations for the proposed information collections must be mailed within 60 days of this notice directly to the HCFA Paperwork Clearance Officer designated at the following address: HCFA, Office of Information Services, Security and Standards Group, Division of HCFA Enterprise Standards, Attention: Dawn Willinghan, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.