Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (MBES/CBES Forms CMS-21 and -21B, -37, and -64) -- (CMS-10529)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-64 Unfilled Form	Form	Unchanged	Available
Form CMS-64 Medical Assistance Expenditures by Type of Service For the Medical Assistance Program	Form	Unchanged	Available
Form CMS-37.3 Summary Medicaid Program Budget Report	Form	Modified	Available
Form CMS-37 Medicaid Program Budget Report	Form	Modified	Available
Form CMS-21B Children's Health Insurance Program Budget Report for the Title XXI	Form and Instruction	Unchanged	Available
Form CMS-21 Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI	Form and Instruction	Unchanged	Available
37.3 Summary Justification for Nonsubstantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-07-28	Available
CMS-10529 - Supporting Statement A (2021 version 3).docx	Supporting Statement A	Uploaded 2021-07-28	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	Unchanged	Unfilled Form
213568	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form	Unchanged	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	Modified	Medicaid Program Budget Report
213567	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	Form	Modified	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	Unchanged	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	Unchanged	Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI

ICR Details

OMB Control No: 0938-1265	ICR Reference No: 202107-0938-017
Status: Historical Active	Previous ICR Reference No: 202101-0938-011
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 (MBES/CBES Forms CMS-21 and -21B, -37, and -64) -- (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 without change	Conclusion Date: 07/29/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/29/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	04/30/2024	04/30/2024
Responses	672	0	672
Time Burden (Hours)	18,144	0	18,144
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): PL: Pub.L. 116 - 16 7 Name of Law: Medicaid Services Investment and Accountability Act of 2019
   PL: Pub.L. 115 - 123 53102 Name of Law: Bipartisan Budget Act of 2018
   PL: Pub.L. 111 - 148 2301, 2501, and 2703 Name of Law: Affordable Care Act of 2009 (ACA)
   PL: Pub.L. 111 - 152 4701 and 5001 Name of Law: Affordable Care Act of 2009 (ACA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT82	Final or interim final rulemaking	85 FR 87000	12/31/2020

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 37286	06/19/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 87000	12/31/2020
Did the Agency receive public comments on this ICR? Yes

---

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, CMS-37.3 Summary	Medicaid Program Budget Report ,   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

---

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)	18,144	18,144	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: This 2020 information collection request is associated with our December 31, 2020, final rule (CMS-2482-F, RIN 0938-AT82). The rule implements provisions of Bipartisan Budget Act of 2018 (BBA 2018) (Pub. L. 115-123), which includes several provisions that modify COB and TPL in relation to special treatment of certain types of care and payment in Medicaid and Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (Pub. L. 111-3). Under the authority in section 1902(a)(25)(A) of the Act, our regulations at 42 CFR part 433, subpart D establishes requirements for state Medicaid agencies to support the coordination of benefits (COB) effort by identifying TPL. Sections 433.139(b)(2), (b)(3)(i) and (b)(3)(ii)(B) detail the exception to standard COB cost avoidance by allowing pay and chase for certain types of care, as well as the timeframe allowed prior to Medicaid paying claims for certain types of care. As detailed below in section 15, we estimate it will take a 224 total hours at a cost of $7,849 to collect information on TPL and report that information to CMS on CMS-64 on a quarterly basis. Since CMS-64 does not require expenditures to be reported by service type, the CMS-64 form does not require any such revisions.

---

Annual Cost to Federal Government: $3,492,571

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? Yes

---

Common Form ICR:  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:

(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: 07/29/2021

---