[Federal Register Volume 63, Number 141 (Thursday, July 23, 1998)]
[Notices]
[Pages 39583-39585]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-19577]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

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


Agency Information Collection Activities: Proposed Collection; 
Comment Request

    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, is 
publishing the following summary of proposed collections for public 
comment. Interested persons are invited to send comments regarding the 
burden estimate or any other aspect of this collection of information, 
including any of the following subjects: (1) the necessity and utility 
of the proposed information collection for the proper performance of 
the agency's functions; (2) the accuracy of the estimated burden; (3) 
ways to enhance the quality, utility, and clarity of the information to 
be collected; and (4) the use of automated collection techniques or 
other forms of information technology to minimize the information 
collection burden.
    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

[[Page 39584]]

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:

<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 from 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

[[Page 39585]]

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 for the proposed 
paperwork collections referenced above, access HCFA's WEB SITE ADDRESS 
at http://www.hcfa.gov/regs/prdact95.htm, or E-mail your request, 
including your address and phone number, to P<a href="/cdn-cgi/l/email-protection#99f8e9fcebeef6ebf2d9f1fafff8b7fef6ef"><span class="__cf_email__" data-cfemail="0160716473766e736a41696267602f666e77">[email protected]</span></a>, or call 
the Reports Clearance Office on (410) 786-1326. Written comments and 
recommendations for the proposed information collections must be mailed 
within 60 days of this notice directly to the HCFA Paperwork Clearance 
Officer designated at the following address: HCFA, Office of 
Information Services, Security and Standards Group, Division of HCFA 
Enterprise Standards, Attention: John Rudolph, Room C2-26-17, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850.

    Dated: July 9, 1998.
John P. Burke III,
HCFA Reports Clearance Officer, Division of HCFA Enterprise Standards, 
Security and Standards Group, Health Care Financing Administration.
[FR Doc. 98-19577 Filed 7-22-98; 8:45 am]
BILLING CODE 4120-03-P


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