Federal Register: July 23, 1998 (Volume 63, Number 141)NoticesPage 39583-39585From the Federal Register Online via GPO Access [wais.access.gpo.gov]

DOCID:fr23jy98-78

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, 64.9dAgency 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:

<bullet> 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.

<bullet> 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.

<bullet> 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 filedfor each waiver including HCBS waivers.

<bullet> 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.

<bullet> 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.

<bullet> 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.

<bullet> 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.

<bullet> 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.

<bullet> 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. 98-19577Filed7-22-98; 8:45 amBILLING CODE 4120-03-P