[Federal Register Volume 63, Number 141 (Thursday, July 23, 1998)]
[Notices]
[Pages 39583-39585]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-19577]
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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 Paperwork@hcfa.gov, 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
