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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0067
ICR Reference No:
200202-0938-005
Status:
Historical Active
Previous ICR Reference No:
199812-0938-002
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
04/08/2002
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/07/2002
Terms of Clearance:
This information collection request is approved consistent with CMS' e-mail memo of 4/4/2002 and telephone discussions on 4/3, 4/4 & 4/5/2002. As agreed, this clearance covers use of all of the CMS-64 expenditure forms, including the 64.9I & 64.10I forms as submitted. However, the "I" forms are only cleared for the collection of additional expenditure information on supplemental and school-based payments. If CMS wishes to collect expenditure data on any additional types of payments, CMS must request OMB approval of a revision to this collection that incorporates the additional requirements and burden. The burden associated with this collection has been adjusted to include that of the 5 "I" forms already developed. Additional terms of clearance include: (1) CMS must ensure that the OMB number and expiration date are displayed on the initial data entry screen for this collection (2) CMS must add the PRA burden statement, updated to include the burden of the "I" forms and (3) CMS must provide OMB with copies of the revised burden screens by 4/26/02. As discussed on 4/5/02, CMS is using the CMS-64 I forms for the information collection requirements associated with the Upper Payment Limit regulations, which were approved under OMB #0938-0855. For that reason, CMS does not plan to renew approval for that collection upon its expiration in 05/2002. CMS will ensure that future submissions of this package document its use for compliance with UPL regulations Finally, OMB notes that CMS began use of the CMS-64 I forms for obtaining information on school-based claiming prior to receipt of OMB approval, in violation of the PRA. The violation will be documented in OMB's next Information Collection Budget.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2005
06/30/2005
04/30/2002
Responses
224
0
224
Time Burden (Hours)
18,144
0
16,464
Cost Burden (Dollars)
0
0
0
Abstract:
The State Medicaid agencies use the form HCFA-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program to report their actual program benefit costs and administrative expenses to the Centers for Medicare and Medicaid (CMS). CMS uses this information to compute the Federal financial participation for the State's Medicaid Program costs.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program
HCFA-64
ICR Summary 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
224
224
0
0
0
0
Annual Time Burden (Hours)
18,144
16,464
0
1,680
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
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:
02/07/2002
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