Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
7826	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program Form	Migrated

ICR Details

OMB Control No: 0938-0067	ICR Reference No: 200202-0938-005
Status: Historical Active	Previous ICR Reference No: 199812-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/08/2002
	Date Received in OIRA: 02/07/2002
Terms of Clearance: This information collection request is approved consistent with CMS' e-mail memo of 4/4/2002 and telephone discussions on 4/3, 4/4 & 4/5/2002. As agreed, this clearance covers use of all of the CMS-64 expenditure forms, including the 64.9I & 64.10I forms as submitted. However, the "I" forms are only cleared for the collection of additional expenditure information on supplemental and school-based payments. If CMS wishes to collect expenditure data on any additional types of payments, CMS must request OMB approval of a revision to this collection that incorporates the additional requirements and burden. The burden associated with this collection has been adjusted to include that of the 5 "I" forms already developed. Additional terms of clearance include: (1) CMS must ensure that the OMB number and expiration date are displayed on the initial data entry screen for this collection (2) CMS must add the PRA burden statement, updated to include the burden of the "I" forms and (3) CMS must provide OMB with copies of the revised burden screens by 4/26/02. As discussed on 4/5/02, CMS is using the CMS-64 I forms for the information collection requirements associated with the Upper Payment Limit regulations, which were approved under OMB #0938-0855. For that reason, CMS does not plan to renew approval for that collection upon its expiration in 05/2002. CMS will ensure that future submissions of this package document its use for compliance with UPL regulations Finally, OMB notes that CMS began use of the CMS-64 I forms for obtaining information on school-based claiming prior to receipt of OMB approval, in violation of the PRA. The violation will be documented in OMB's next Information Collection Budget.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2005	06/30/2005	04/30/2002
Responses	224	0	224
Time Burden (Hours)	18,144	0	16,464
Cost Burden (Dollars)	0	0	0

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Abstract: The State Medicaid agencies use the form HCFA-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program to report their actual program benefit costs and administrative expenses to the Centers for Medicare and Medicaid (CMS). CMS uses this information to compute the Federal financial participation for the State's Medicaid Program costs.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	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	224	0	0	0	0
Annual Time Burden (Hours)	18,144	16,464	0	1,680	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/07/2002

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