Agency Information Collection Activities: Proposed Collection; Comment Request

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:

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 from 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

[[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[email protected], 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