[Federal Register Volume 63, Number 117 (Thursday, June 18, 1998)]
[Notices]
[Pages 33377-33379]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-16221]



[[Page 33377]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[Form # HCFA-21, 21B, 21P, 21.11A, 21E, 64, 64.21, 64.21U, 64.21P, 
64.21UP, 64EC, 64.21E, 64.9P, 64.10P, 64.11A, 64.9d]


Emergency Clearance: Public Information Collection Requirements 
Submitted to the Office of Management and Budget (OMB)

    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Health Care Financing 
Administration (HCFA), Department of Health and Human Services (DHHS), 
has submitted to the Office of Management and Budget (OMB) the 
following request for Emergency review. We are requesting an emergency 
review because the collection of this information is needed prior to 
the expiration of the normal time limits under OMB's regulations at 5 
CFR, Part 1320. The Agency cannot reasonably comply with the normal 
clearance procedures because of the need for States to report financial 
and related statistical information pursuant to the operation of their 
Medicaid programs, under title XIX of the Social Security Act, and 
their Children's Health Insurance Programs (CHIP) under title XXI of 
the Act. States will begin reporting information after the end of the 
third quarter of Federal fiscal year 1998 (after June 30, 1998). 
Without the capacity for States to report this information discussed 
below, the States and HCFA will not be able to properly implement the 
provisions enacted by the Balanced Budget Act (BBA) of 1997 related to 
the CHIP.
    HCFA is requesting OMB review and approval of this collection 
within eleven working days, with a 180-day approval period. Written 
comments and recommendations will be accepted from the public if 
received by the individual designated below, within ten working days of 
publication of this notice in the Federal Register.
    During this 180-day period HCFA will pursue OMB clearance of this 
collection as stipulated by 5 CFR 1320.5.
(1) Type of Information Collection Request: New Collection;
    Title of Information Collection: Children's Health Insurance 
Program (CHIP) Budget and Expenditure System State Reporting Forms.
    Form Nos.: HCFA-21, 21B, 21P, 21.11A, 21E;
    Use: These forms will be used by State CHIP agencies to report CHIP 
program budget projections and actual CHIP program benefits and 
administrative expenditures, and the numbers of children being served 
in the CHIP program, to the Health Care Financing Administration 
(HCFA). The information provided by these new forms will be used by 
HCFA to prepare the grant awards to States for the CHIP, to ensure that 
the appropriate level of Federal payments for State expenditures under 
the CHIP are made in accordance with the CHIP-related BBA legislative 
provisions of 1997, and to track, monitor, and evaluate the numbers of 
children being served by the CHIP.

    Note: At this time Form HCFA-21E of this package is for States 
to report the numbers of children, by service delivery system, that 
are served in the States' CHIPs based on age categories. However, we 
are continuing to work with the States to develop an appropriate 
format for States to report the numbers of children, by service 
delivery system, that are served in the CHIP based on Federal 
poverty income level categories and under the age categories 
previously requested. When this format is finalized it will be 
incorporated into Form HCFA-21E.

    For a short description of the CHIP reporting forms, see below:
    <bullet> Form HCFA-21 Summary Sheet. Quarterly Children's Health 
Insurance Program Statement of Expenditures for Title XXI Summary 
Sheet. This form summarizes the total expenditures in the State's CHIP 
reported by the State for the reporting quarter.
    <bullet> Form HCFA-21. Children's Health Expenditures by Type of 
Service for the Title XXI Program, Expenditures in this Quarter. States 
use this form to report CHIP current quarter expenditures in accordance 
with services categories authorized under title XXI.
    <bullet> Form HCFA-21B. Children's Health Insurance Program Budget 
Report for the Title XXI Program State Expenditure Plan. States use 
this form to report their budget projections each quarter for their 
Title XXI CHIPs for the current and budget Federal fiscal years and 
broken out by quarter.
    <bullet> Form HCFA-21P. Children's Health Expenditures by Type of 
Service for the Title XXI Program, Prior Period Adjustments. States use 
this form to report CHIP prior period adjustment expenditures claimed 
in the submission quarter in accordance with services categories 
authorized under title XXI.
    <bullet> Form HCFA-21.11A. Provider-Related Donations and Health 
Care Related Taxes, Fees, and Assessments Received Under Section 
1903(w) for Title XXI. States use this form to report CHIP-related 
State receipts of provider related donations, and health care related 
taxes, fees, and assessments.
    <bullet> Form HCFA-21E. Children's Health Insurance Program, Number 
of Children Served. States use this form to report the numbers of 
children, by service delivery system, that are served in the States' 
CHIPs based on age categories.

    Note: HCFA is working with States to develop an appropriate 
format for States to report numbers of children, by service delivery 
system, that are served in the CHIP based on Federal poverty income 
level categories and under the age categories previously requested. 
When the format is finalized it will be incorporated into this form.

    Frequency: Quarterly;
    Affected Public: State and Federal government;
    Number of Respondents: 56;
    Total Annual Responses: 224;
    Total Annual Hours: 7,840.
    (2) Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Quarterly 
Medicaid Statement of Expenditures for the Medical Assistance Program.
    Form Nos.: HCFA-64, 64.21, 64.21U, 64.21P, 64.21UP, 64EC, 64.21E, 
64.9, 64.10, 64.10P, 64.11a, 64.9d;
    Use: These new forms are revisions of the currently approved 
collection report Form HCFA-64. These forms will be used by State 
Medicaid agencies to report their actual CHIP-related Medicaid 
expenditures and the numbers of CHIP-related children, and other 
children being served in the Medicaid program, to the Health Care 
Financing Administration(HCFA). The forms will be used by the HCFA to 
ensure that the appropriate level of Federal payments for the State's 
CHIP-related Medicaid program expenditures are made in accordance with 
the CHIP and related Medicaid provisions of the BBA of 1997, and to 
track, monitor, and evaluate the numbers of CHIP-related children and 
other individuals being served by the Medicaid program.

    Note: At this time Forms HCFA-64.21E and HCFA-64EC of this 
package are for States to report the numbers of CHIP-related 
children and other children, by service delivery system, that are 
served in States' Medicaid programs based on age categories. 
However, we are continuing to work with the States to develop an 
appropriate format for States to report the numbers of children, by 
service delivery system, that are served in the States' Medicaid 
programs based on Federal poverty income level categories and under 
the age categories previously requested. When this format is 
finalized it will be incorporated into Forms HCFA-21E and HCFA-64EC.

    For a short description of the CHIP-related Medicaid reporting 
forms, see below:

[[Page 33378]]

<bullet> HCFA-64 SUMMARY SHEET
    Quarterly Medicaid Statement of Expenditures for the Medical 
Assistance Program, Summary Sheet. The form HCFA-64 summary sheet is a 
one-page summary sheet summarizing the total expenditures reported for 
the quarter. The remaining forms provide additional detail and support 
the entries made on the summary sheet.
<bullet> HCFA-64.9
    Quarterly Medicaid Statement of Expenditures for the Medical 
Assistance Program, Expenditures in this Quarter. The form HCFA-64.9 is 
comprised of two pages that are used for detailing, by category, 
current quarter program expenditures by type of service (e.g., clinical 
services, dental services). The total figures from the form HCFA-64.9 
are transferred to the form HCFA-64 Summary Sheet, Line 6, columns (a) 
and (b). A separate copy of the form HCFA-64.9 must also be submitted 
for each waiver granted to the State agency for which expenditures have 
been incurred. The total waiver figures are already incorporated in the 
expenditures reported on the ``base'' (one form) form HCFA-64.9.
<bullet> HCFA-64.9p
    Quarterly Medicaid Statement of Expenditures for the Medical 
Assistance Program, Prior Period Adjustment. The form HCFA-64.9p 
supports claims or adjustments for prior period (years) which are 
transferred to the form HCFA-64 summary sheet and noted on Lines 7, 8, 
10.A., and 10.B., columns (a) and (b). It contains the same service 
categories as the form HCFA-64.9. This two-page form details the 
program expenditures, by category, arraying the expenditures by fiscal 
year. A separate form HCFA-64.9p is prepared to support each fiscal 
year and each line entry (Lines 7, 8, 10.A., and 10.B.) on the summary 
sheet. If the prior period adjustment includes waiver-related 
expenditures, a separate form HCFA-64.9p must be filed for each waiver 
including HCBS waivers.
<bullet> HCFA-64.9d
    Allocation of Disproportionate Share Hospital Payment Adjustments 
to Applicable FFYs. The form HCFA-64.9d has been created to track 
payments of DSH by Federal Fiscal Year. This one page form details, by 
Inpatient Hospital Services and Mental Health Facility Services, 
details the allotment and DSH payments by Federal Fiscal Years. This is 
authorized under Sec. 1923(f) of the Act.
<bullet> HCFA-64.10
    Expenditures for State and Local Administration for the Medical 
Assistance Program, Expenditures in this Quarter. The form HCFA-64.10 
supports administrative expenditures reported on the summary sheet. 
This one page form details, by category, the current quarter 
expenditures for administering the Medicaid program. The total figures 
from the ``base'' form HCFA-64.10 summary sheet. The State agency must 
also file a separate form HCFA-64.10 or each of its waivers granted to 
the State agency for which expenditures have been incurred. The waiver 
expenditures reported on a supporting form HCFA-64.10 are already 
included with the overall expenditures reported on the ``base'' form 
HCFA-64.10.
<bullet> HCFA-64.10p
    Expenditures for State and Local Administration for the Medical 
Assistance Program, Prior Period Adjustments. The form HCFA-64.10p is 
similar to the form HCFA-64.10 except that it addresses adjustments to 
prior period expenditures. The totals from the form HCFA-64.10p are 
transferred to the form HCFA-64 summary sheet, Lines 7, or 8. or 10.A., 
or 10.B., columns (c) and (d). A separate form HCFA-64.10p must be 
completed for each line item entry, by fiscal year, on the summary 
sheet.
<bullet> HCFA-64.11
    Summary Total of Receipts from form HCFA-64.11A. The form HCFA-
64.11 has been created to summarize the information reported on the 
various HCFA-64.11a forms. This is authorized under Sec. 1903(w) of the 
Act.
<bullet> HCFA-64.11A
    Actual Receipts by Plan Name. The form HCFA-64.11a has been created 
to report the actual receipts by plan names form provider-related 
donation and health care related taxes, fees and assessments. This is 
authorized under Sec. 1903(w) of the Act.
    <bullet> There are no forms numbered 64.1 through 64.8 because of 
form development and redevelopment over the years. There are also no 
forms detailing items 9.B. through 9.E. of the summary sheet because 
there is no need for further breakdown of these figures for 
reimbursement calculations.
    HCFA-64.21  Quarterly Medical Assistance Expenditure By Children's 
Health Insurance Program Expenditure Categories. States will use this 
form to report current quarter expenditures for children who are 
determined presumptively eligible under section 1920A of the Act.
    HCFA-64.21U  Quarterly Medical Assistance Expenditure Categories by 
Children's Health Insurance Program Expenditure Categories. States will 
use this form to report current quarter expenditures described under 
section 1905(u)(2) and 1905(u)(3) of the Act.
    HCFA-64.21P  Quarterly Medical Assistance Expenditures By 
Children's Health Insurance Program expenditure categories. States will 
use this form to report prior period expenditures for children who are 
determined presumptively eligible under section 1920A of the Act.
    HCFA-64.21UP  Quarterly Medical Assistance Expenditures by 
Children's Health Insurance Program Expenditure Categories, Prior 
Period Expenditures. States will use this form to report prior period 
expenditures described under section 1905(u)(2) and (3) of the Act.
    HCFA-64.21E  Number of Children Served Related to Children's Health 
Insurance Program. States use this form to report the numbers of CHIP-
related children, by service delivery system, that are served in the 
States' Medicaid programs based on age categories.

    Note: HCFA is working with States to develop an appropriate 
format for States to report numbers of CHIP-related children, by 
service delivery system, that are served in the States' Medicaid 
programs related to CHIP based on Federal poverty income level 
categories and under the age categories previously requested. When 
the format is finalized it will be incorporated into this form.

    HCFA-64EC  Number of Children Served Related to Children's Health 
Insurance Program. States use this form to report the numbers of 
children (other than CHIP-related children), by service delivery 
system, that are served in the States' Medicaid programs based on age 
categories.
    Note: HCFA is working with States to develop an appropriate 
format for States to report numbers of children (other than CHIP-
related children), by service delivery system, that are served in 
the Medicaid program based on Federal poverty income level 
categories and under the age categories previously requested. When 
the format is finalized it will be incorporated into this form.
    Frequency: Quarterly;
    Affected Public: State and Federal government;
    Number of Respondents: 56;
    Total Annual Responses: 224;
    Total Annual Hours: 16,464.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access HCFA's 
Web

[[Page 33379]]

Site address at http://www.hcfa.gov/regs/prdact95.htm, or E-mail your 
request, including your address, phone number, OMB number, and HCFA 
document identifier, to P<a href="/cdn-cgi/l/email-protection#a6c7d6c3d4d1c9d4cde6cec5c0c788c1c9d0"><span class="__cf_email__" data-cfemail="ed8c9d889f9a829f86ad858e8b8cc38a829b">[email protected]</span></a>, or call the Reports 
Clearance Office on (410) 786-1326.
    HCFA is requesting OMB review and approval of these collections 
within eleven working days of publication in the Federal Register. 
However, comments on these information collections and record keeping 
requirements must be received by the designees referenced below, within 
ten working days of publication in the Federal Register: Office of 
Information and Regulatory Affairs, Office of Management and Budget, 
Room 10235, New Executive Office Building, Washington, DC 20503, Fax 
Number: (202) 395-6974 or (202) 395-5167, Attn: Laura Oliven , HCFA 
Desk Officer.

    Dated: June 9, 1998.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA, Office of Information Services, 
Security and Standards Group, Division of HCFA Enterprise Standards.

[FR Doc. 98-16221 Filed 6-17-98; 8:45 am]
BILLING CODE 4120-03-P


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