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Agenda
Reg Review
ICR
View Information Collection (IC)
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
Form CMS 64.9VIII
Medical Assistance Expenditures by Type of Service For the Medical Assistance Program
64 9 VIII with New Line Items.pdf
Yes
Yes
Fillable Printable
Form
CMS 64.9 BASE
Medical Assistance Expenditures by Type of Service For the Medical Assistance Program
64 9 with New Line item.pdf
Yes
Yes
Fillable Printable
Form
CMS 64.9T
Medical Assistance Expenditures by Type of Service For the Medical Assistance Program
64 9T with New Line Item.pdf
Yes
Yes
Fillable Printable
Form
CMS 64.21
Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Expenditure Categories
64 21 with Newl Line item.pdf
Yes
Yes
Fillable Printable
Form
CMS 64.21U
Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Expenditures Categories
64 21U with Newl Line item.pdf
Yes
Yes
Fillable Printable
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
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)
8,960
0
0
0
0
8,960
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk
Crosswalk for the implementation of P L 113-93 Behavior Health.pdf
09/09/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.