Information Collection

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

IC 213568 under ICR 202109-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-64 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
CMS-64 Medical Assistance Expenditures by Type of Service For t 64 Summary.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form
CMS-64 Medical Assistance Expenditures by Type of Service For t 64 Summary.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form
CMS-64 Unfilled Form 64 Blank Forms.pdf	Form
CMS-64 Unfilled Form 64 Blank Forms.pdf	Form
CMS-64.9 CMS 64.9 ARP 9817 Reinvest Form (FMAP Rate + 10%) 64.9 ARP 9817 Reinvest FMAP Rate +10%.pdf	Form
CMS-64.9 CMS 64.9 ARP 9817 Reinvest Form (FMAP Rate + 10%) 64.9 ARP 9817 Reinvest FMAP Rate +10%.pdf	Form
CMS-64.9 CMS-64.9 ARP 9817 CMS-64.9 ARP 9817.pdf	Form
CMS-64.9 CMS-64.9 ARP 9817 CMS-64.9 ARP 9817.pdf	Form
CMS-64.9 ARP Section 9811 (Line 47) Section 9811 CMS-64.9.pdf	Form
CMS-64.9 ARP Section 9811 (Line 47) Section 9811 CMS-64.9.pdf	Form
CMS-64.21U ARP Section 9821 (Line 26) Section 9821 CMS-64.21U.pdf	Form
CMS-64.21U ARP Section 9821 (Line 26) Section 9821 CMS-64.21U.pdf	Form
CMS-64.9 CMS-64.9 ARP 9817 Reinvest Form (Regular FMAP) 64.9 ARP 9817 Reinvest Regular FMAP.pdf	Form
CMS-64.9 CMS-64.9 ARP 9817 Reinvest Form (Regular FMAP) 64.9 ARP 9817 Reinvest Regular FMAP.pdf	Form
Crosswalk for the 64.9 ARP Section 9811 New line.xlsx CROSSWALK - Form CMS-64.9	IC Document
Crosswalk for the 64.9 ARP Section 9811 New line.xlsx CROSSWALK - Form CMS-64.9	IC Document
Crosswalk for the 64.21U ARP Section 9821 New line.xlsx CROSSWALK - Form CMS-64.21U	IC Document
Crosswalk for the 64.21U ARP Section 9821 New line.xlsx CROSSWALK - Form CMS-64.21U	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-64	Medical Assistance Expenditures by Type of Service For the Medical Assistance Program	64 Summary.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Printable
Form	CMS-64	Unfilled Form	64 Blank Forms.pdf		Yes	Yes	Fillable Printable
Form	CMS-64.9	CMS 64.9 ARP 9817 Reinvest Form (FMAP Rate + 10%)	64.9 ARP 9817 Reinvest FMAP Rate +10%.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.9	CMS-64.9 ARP 9817	CMS-64.9 ARP 9817.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.9	ARP Section 9811 (Line 47)	Section 9811 CMS-64.9.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.21U	ARP Section 9821 (Line 26)	Section 9821 CMS-64.21U.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.9	CMS-64.9 ARP 9817 Reinvest Form (Regular FMAP)	64.9 ARP 9817 Reinvest Regular FMAP.pdf		Yes	Yes	Fillable Fileable

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)	9,184	9,184
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CROSSWALK - Form CMS-64.9	Crosswalk for the 64.9 ARP Section 9811 New line.xlsx	09/03/2021
CROSSWALK - Form CMS-64.21U	Crosswalk for the 64.21U ARP Section 9821 New line.xlsx	09/03/2021

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