Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program

ICR 199803-0938-012

OMB: 0938-0067

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0067 199803-0938-012
Historical Active 199501-0938-001
HHS/CMS
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
Extension without change of a currently approved collection   No
Regular
Approved without change 05/26/1998
Retrieve Notice of Action (NOA) 03/30/1998
This information collection is approved as amended by the 5-21-98 fax from HCFA.
  Inventory as of this Action Requested Previously Approved
05/31/2001 05/31/2001 05/31/1998
224 0 228
11,984 0 13,566
0 0 0

The form HCFA-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program, has been used since January 1980 by the Medicaid State agencies to report their actual program benefit costs and administrative expenses to the Health Care Financing Administration (HCFA). HCFA uses this information to compute the Federal financial participation (FFP) for the State's Medicaid program costs. The form HCFA-64 has been modified over the years to incorporate legislative, regulatory, and operational changes. At this time, we are not requesting any revisions to the existing....

None
None


No

1
IC Title Form No. Form Name
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program HCFA-64

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 224 228 0 0 -4 0
Annual Time Burden (Hours) 11,984 13,566 0 0 -1,582 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/30/1998


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