Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (CMS-10529)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-64.9 (base) Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	Form and Instruction	New	Available
Form CMS-64 (Summary) Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	Form and Instruction	New	Available
Form CMS-37 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	Form and Instruction	New	Available
Form CMS-21B Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI	Form and Instruction	New	Available
Form CMS-21 Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI	Form and Instruction	New	Available
Response to Alabama Comment.docx	Supplementary Document	Uploaded 2014-10-22	Available
CMS-10529 - Supporting Statement A rev 12-15-2014 at 1130 am -- CLEAN.docx	Supporting Statement A	Uploaded 2014-12-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213568	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form and Instruction	New	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
213568	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form and Instruction	New	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
213567	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	Form and Instruction	New	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
213566	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	Form and Instruction	New	Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI
213566	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	Form and Instruction	New	Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI

ICR Details

OMB Control No: 0938-1265	ICR Reference No: 201410-0938-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (CMS-10529)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/23/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/22/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved
Responses	672	0	0
Time Burden (Hours)	17,920	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: MBES/CBES is a financial reporting system that produces Budget and expenditures for Medical Assistance and Children's Health Insurance Program. All forms (CMS-21, -21B, -37, and -64) are to be filed on a quarterly basis and need to be certified by the States to the CMS.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 46442	08/08/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 62628	10/20/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	CMS-21, CMS-21B	Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI ,   Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	CMS-37	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	CMS-64 (Summary), CMS-64.9 (base)	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program ,   Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program

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ICR Summary of Burden

table that charts list 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	672	0	0	672	0	0
Annual Time Burden (Hours)	17,920	0	0	17,920	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: While this is a new package, it responds to the Terms of Clearance issued on July 2, 2013, under OCN 0938-0067 (CMS-64). The Terms state: "Approved consistent with the understanding that, within 18 months, CMS plans to obtain approval for the electronic MBES system. Once the MBES is approved, CMS will discontinue the following OMB control numbers and incorporate the data collection instruments into MBES: 0938-0101, 0938-0067, and 0938-0731." In this regard, this package seeks to consolidate CMS-21 and -21B (OMB# 0938-0731), CMS-37 (OMB# 0938-0101), and CMS-64 (OMB# 0938-0067) under a new control number while keeping the individual forms as separate instruments using their original CMS identification numbers. The consolidated package's CMS identification number is CMS-10529. We acknowledge that the control numbers for CMS-21 and -21B (OMB# 0938-0731), CMS-37 (OMB# 0938-0101), and CMS-64 (OMB# 0938-0067) will be formally discontinued upon the approval of CMS-10529.

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Annual Cost to Federal Government: $2,373,420

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 10/22/2014

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