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 Unfilled Form	Form	Modified	Available
Form CMS-64 Medical Assistance Expenditures by Type of Service For the Medical Assistance Program	Form	Modified	Available
Form CMS-37 Medicaid Program Budget Report	Form	Unchanged	Available
Form CMS-21B Children's Health Insurance Program Budget Report for the Title XXI	Form and Instruction	Modified	Available
Form CMS-21 Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI	Form and Instruction	Modified	Available
Justification for Nonsubstantive Change (version 2).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-03-22	Available
CMS-10529 - Supporting Statement A rev 12-18-2017 by OSORA PRA _ Feedba CLEAN.docx	Supporting Statement A	Uploaded 2018-03-29	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	Modified	Unfilled Form
213568	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form	Modified	Medical Assistance Expenditures by Type of Service For the Medical Assistance Program
213567	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	Form	Unchanged	Medicaid Program Budget Report
213566	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	Form and Instruction	Modified	Children's Health Insurance Program Budget Report for the Title XXI
213566	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	Form and Instruction	Modified	Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI

ICR Details

OMB Control No: 0938-1265	ICR Reference No: 201901-0938-004
Status: Historical Active	Previous ICR Reference No: 201712-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (CMS-10529)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/10/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/22/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	04/30/2021	04/30/2021
Responses	672	0	672
Time Burden (Hours)	17,920	0	17,920
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:
	82 FR 46063	10/03/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 58209	12/11/2017
Did the Agency receive public comments on this ICR? No

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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 ,   Children's Health Insurance Program Budget Report for the Title XXI
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	CMS-37	Medicaid Program Budget Report
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	CMS-64, CMS-64	Medical Assistance Expenditures by Type of Service For the Medical Assistance Program ,   Unfilled Form

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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	672	0	0	0	0
Annual Time Burden (Hours)	17,920	17,920	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $3,525,622

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 03/22/2019

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