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

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)

OMB: 0938-1265

IC ID: 213568

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Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)
 
No Modified
 
Mandatory
 

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 Children’s Health Insurance Program VALUE Based 64.21U Change for Section 508 Compliance.pdf Yes Yes Fillable Fileable
Form CMS-10529 CMS-64.10 CMS-64 10 LINE 31 Section 508 Compliant (2023 version 1).pdf Yes Yes Fillable Fileable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 224 0 0 0 0 224
Annual IC Time Burden (Hours) 9,184 0 0 0 0 9,184
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk: CMS-64.10 Crosswalk for the CAA 2023 Section 5101 New line.xlsx 11/07/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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