Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

Forms and Documents

Document Name	Status
Form CMS-64 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program Form	Modified
Comments CMS.64 [to OMB].doc Supplementary Document	2011-02-26
CMS-64 - Crosswalk.xlsx Supplementary Document	2011-02-26
CMS-64 Disclosure Statement.doc Supplementary Document	2008-06-06
CMS-64 Supporting Statement [rev 02-2011].doc Supporting Statement A	2011-02-26

IC Document Collections

IC ID	Document Title	Status
7827	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program Form	Modified

ICR Details

OMB Control No: 0938-0067	ICR Reference No: 201103-0938-010
Status: Historical Active	Previous ICR Reference No: 200806-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/22/2011
	Date Received in OIRA: 03/21/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	08/31/2011
Responses	224	0	224
Time Burden (Hours)	18,144	0	18,144
Cost Burden (Dollars)	0	0	0

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Abstract: The State Medicaid agencies use the Form CMS-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program to report their actual program benefit costs and administrative expenses to the Centers for Medicare and Medicaid Services (CMS). CMS uses this information to compute the Federal financial participation for the State's Medicaid Program costs.

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Authorizing Statute(s): PL: Pub.L. 105 - 33 1900 Name of Law: State Children's Health Insurance Program
   PL: Pub.L. 105 - 100 1903 Name of Law: Payments to States
   Statute at Large: 19 Stat. 1903 Name of Statute: null
   PL: Pub.L. 111 - 152 4107 and 5001 Name of Law: Affordable care Act of 2009
   PL: Pub.L. 111 - 148 2301, 2501, and 2703 Name of Law: Affordable Care Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 76988	12/10/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 9579	02/18/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	CMS-64	Quarterly Medicaid Statement of Expenditures

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	224	224	0	0	0	0
Annual Time Burden (Hours)	18,144	18,144	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,061,212

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/21/2011

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