Information Collection

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

IC 213568 under ICR 201609-0938-003 · OMB 0938-1265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1265 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form CMS 64.9VIII Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
Form CMS 64.9 BASE Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
Form CMS 64.9T Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
Form CMS 64.21 Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Expenditure Categories Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
Form CMS 64.21U Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Expenditures Categories Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
Form CMS 64.9VIII Medical Assistance Expenditures by Type of Service For t 64 9 VIII with New Line Items.pdf	Form
CMS 64.9 BASE Medical Assistance Expenditures by Type of Service For t 64 9 with New Line item.pdf	Form
CMS 64.9T Medical Assistance Expenditures by Type of Service For t 64 9T with New Line Item.pdf	Form
CMS 64.21 Quarterly Medical Assistance Expenditures By Children's 64 21 with Newl Line item.pdf	Form
CMS 64.21U Quarterly Medical Assistance Expenditures By Children's 64 21U with Newl Line item.pdf	Form
Crosswalk for the implementation of P L 113-93 Behavior Health.pdf Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form CMS 64.9VIII	Yes	Yes	Fillable Printable
Form	CMS 64.9 BASE	Yes	Yes	Fillable Printable
Form	CMS 64.9T	Yes	Yes	Fillable Printable
Form	CMS 64.21	Yes	Yes	Fillable Printable
Form	CMS 64.21U	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	8,960	8,960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		09/09/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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