Information Collection

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

IC 213568 under ICR 202208-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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
CMS-64.9 Quarterly Medicaid Assistance Program Expenditures by Ty ACE KIDS Value Based 64.9 for Section 508 Compliance.pdf Form
CMS-64.9 Quarterly Medicaid Assistance Program Expenditures by Ty ACE KIDS Value Based 64.9 for Section 508 Compliance.pdf Form
CMS-64.9T Quarterly Medicaid Assistance Program Expenditures by Ty New ACE KIDS VALUE BASED 64.9T for Section 508 Compliance.pdf Form
CMS-64.9T Quarterly Medicaid Assistance Program Expenditures by Ty New ACE KIDS VALUE BASED 64.9T for Section 508 Compliance.pdf Form
CMS-64.21U Quarterly Medicaid Assistance Expenditures by Children’s VALUE Based 64.21U Change for Section 508 Compliance.pdf Form
CMS-64.21U Quarterly Medicaid Assistance Expenditures by Children’s VALUE Based 64.21U Change for Section 508 Compliance.pdf Form
Crosswalk for the 64.9 ACE KIDS Value Based New line CK.xlsx Crosswalk: CMS-64.9 IC Document
Crosswalk for the 64.9 ACE KIDS Value Based New line CK.xlsx Crosswalk: CMS-64.9 IC Document
Crosswalk for the 64.9T ACE KIDS Value Based New line -CK.xlsx Crosswalk: CMS-64.9T IC Document
Crosswalk for the 64.9T ACE KIDS Value Based New line -CK.xlsx Crosswalk: CMS-64.9T IC Document
Crosswalk for the 64.21U Series Value Based New line - CK.xlsx Crosswalk: CMS-64.21U IC Document
Crosswalk for the 64.21U Series Value Based New line - CK.xlsx Crosswalk: 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:

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
Form	CMS-64.9	Quarterly Medicaid Assistance Program Expenditures by Type of Service	ACE KIDS Value Based 64.9 for Section 508 Compliance.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.9T	Quarterly Medicaid Assistance Program Expenditures by Type of Service: Qualifying State	New ACE KIDS VALUE BASED 64.9T for Section 508 Compliance.pdf		Yes	Yes	Fillable Fileable
Form	CMS-64.21U	Quarterly Medicaid Assistance Expenditures by Childrenâs Health Insurance Program	VALUE Based 64.21U Change for Section 508 Compliance.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 %

	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

Title	Document	Date Uploaded
Crosswalk: CMS-64.9	Crosswalk for the 64.9 ACE KIDS Value Based New line CK.xlsx	08/25/2022
Crosswalk: CMS-64.9T	Crosswalk for the 64.9T ACE KIDS Value Based New line -CK.xlsx	08/25/2022
Crosswalk: CMS-64.21U	Crosswalk for the 64.21U Series Value Based New line - CK.xlsx	08/25/2022

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