Agency Information Collection Activities: Submission for OMB Review; Comment Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[Document Identifier: (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)]

Agency Information Collection Activities: Submission for OMB

Review; 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, has

submitted to the Office of Management and Budget (OMB) the following

proposal for the collection of information. 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.

(1) 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.

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 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

[[Page 66553]]

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.

(2) Type of Information Collection Request: Revision of a currently

approved 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, 21L;

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.

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: 448;

Total Annual Hours: 7,840.

To obtain copies of the supporting statement for the proposed

paperwork collections referenced above, 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 30 days of this notice directly to the OMB Desk Officer

designated at the following address: OMB Human Resources and Housing

Branch, Attention: Allison Eydt, New Executive Office Building, Room

10235, Washington, D.C. 20503.

Dated: November 16, 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. 98-32125 Filed 12-1-98; 8:45 am]

BILLING CODE 4120-03-P