[Federal Register Volume 63, Number 117 (Thursday, June 18, 1998)]
[Notices]
[Pages 33377-33379]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-16221]
[[Page 33377]]
-----------------------------------------------------------------------
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 Paperwork@hcfa.gov, 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
