[Federal Register Volume 63, Number 231 (Wednesday, December 2, 1998)]
[Notices]
[Pages 66552-66553]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-32125]



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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