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

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:

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.

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.

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.

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.

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.

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]]

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.

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.

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.

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.

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.

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.

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.

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.

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[email protected], 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