Form CMS-21 Quarterly State Children's Health Insurance Program Stat

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

Quarterly State Children's Health Insurance Program
Statement of Expenditures for Title XXI
Summary Sheet
State:

Quarter Ended:
Title XXI Expenditures

Expenditures Reported for Period

1

Expenditures In This Quarter (Form CMS 21 Base)

2

Adjustments Increasing Claims For Prior Quarters
(Form CMS 21P)

3

Adjustments Decreasing Claims For Prior Quarters
(Form CMS 21P)

4

Net Expenditures Reported In This Period

Total Computable

Federal Share

(A)

(B)

I certify that:
1. I am the executive officer of the state agency or his/her designate authorized by the state to submit this form.
2. This report only includes expenditures under the State Children’s Health Insurance Program (SCHIP) under Title XXI of the Act that are allowable in
accordance with applicable implementing federal, state, and local statutes, regulations, policies, and the state Child Health Plan approved by the Secretary and
in effect in the Quarter Ended indicated above under Title XXI of the Act.
3. The expenditures included in this report are based on the state's accounting of actual recorded expenditures, and are not based on estimates.
4. The required amount of state and/or local funds were available and used to match the state’s allowable expenditures included in this report, and such state
and/or local funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. Federal matching funds are not being claimed on this report to match any expenditure under any state Child Health Plan amendment that was submitted after
January 2, 2001, and that has not been approved by the Secretary effective for the Quarter Ended indicated above.
6. The information shown above and on the Form CMS-21 Summary Sheet and the Supporting Schedules is correct to the best of my knowledge and belief.
Date:
Signature:
Title:
User Performing Certification:
FOOTNOTES:

The completed Budget, Expenditure and supporting forms are to be submitted via the on-line MBES/CBES system to the Centers for Medicare & Medicaid
Services, Center for Medicaid and State Operations, Finance, Systems and Quality Group, Division of Financial Management, located at Mailstop S3-13-15,
7500 Security Blvd., Baltimore, Maryland 21244-1850.

Form CMS 21 Summary Sheet

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

State Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:

Total
Computable
(A)
1A

Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid

1B

Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets

1C

Premiums Over 150% Of Poverty Level - Gross Premiums
Paid

1D

Premiums Over 150% Of Poverty Level - Cost Sharing Offsets

2

Inpatient Hospital Services

3

Inpatient Mental Health Facility Services

4

Nursing Care Services

5

Physician And Surgical Services

6

Outpatient Hospital Services

7

Outpatient Mental Health Facility Services

8

Prescribed Drugs

9

Dental Services

10

Vision Services

11

Other Practitioners' Services

12

Clinic Services

13

Therapy Services

14

Laboratory And Radiological Services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions No.

18

Screening Services

19

Home Health

20

Reserved

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Services

26

Outreach

27

Administration

28

Balance

29

Less: Collections

30

Total

Form CMS 21 Base

Federal
Share
77.33%
(B)

Quarter Ended:
Subject To 10% Limit
Federal
Total
Total
Share
Federal
Computable
77.33%
Share
(C)
(D)
(E)

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

State Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:

Quarter Ended:

Program Code:

Subject To 10% Limit
Total
Computable
(A)

1A

Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid

1B

Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets

1C

Premiums Over 150% Of Poverty Level - Gross Premiums
Paid

1D

Premiums Over 150% Of Poverty Level - Cost Sharing Offsets

2

Inpatient Hospital Services

3

Inpatient Mental Health Facility Services

4

Nursing Care Services

5

Physician And Surgical Services

6

Outpatient Hospital Services

7

Outpatient Mental Health Facility Services

8

Prescribed Drugs

9

Dental Services

10

Vision Services

11

Other Practitioners' Services

12

Clinic Services

13

Therapy Services

14

Laboratory And Radiological Services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions No.

18

Screening Services

19

Home Health

20

Reserved

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Services

26

Outreach

27

Administration

28

Balance

29

Less: Collections

30

Total

Form CMS-21

Federal
Share
77.33%
(B)

Federal
Total

Computable
(C)

Share
77.33%
(D)

Total
Federal
Share
(E)

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

State Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments
State:

Quarter Ended:
Fiscal Year:
Line:

Program Code:

Subect To 10% Limit
Total
Computable
(A)

1A

Premiums Up To 150% Of Poverty Level - Gross Premiums Paid

1B

Premiums Up To 150% Of Poverty Level - Cost Sharing Offsets

1C

Premiums Over 150% Of Poverty Level - Gross Premiums Paid

1D

Premiums Over 150% Of Poverty Level - Cost Sharing Offsets

2

Inpatient Hospital Services

3

Inpatient Mental Health Facility Services

4

Nursing Care Services

5

Physician And Surgical Services

6

Outpatient Hospital Services

7

Outpatient Mental Health Facility Services

8

Prescribed Drugs

9

Dental Services

10

Vision Services

11

Other Pracitioners' Services

12

Clinic Services

13

Therapy Services

14

Laboratory And Radiological Services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions No.

18

Screening Services

19

Home Health

20

Reserved

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Services

26

Outreach

27

Administration

28

Balance

29

Less: Collections

30

Total

Form CMS-21P

Federal
Share
0
(B)

Federal
Total

Computable
(C)

Share
0
(D)

Total
Federal
Share
(E)

Deferral
Disallowance
C.I.N. No.
(F)

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State Children's Health Insurance Program Expenditures
For the Title XXI Program
Calculation of 10% Limit
State:

Quarter Ended:
Total Computable
Federal Share
(A)

1A

Previously Claimed Expenditures - Section 2105(a)(1)

1B

Previously Claimed Expenditures - Section 1905(u)(2) And 1905(u)(3)

2A

Expenditures Claimed In The Current Quarter - Section 2105(a)(1)

2B

Expenditures Claimed In The Current Quarter - Sections 1905(u)(2) And
1905(u)(3)

3

Total Of Column (a) Lines 1A & B And 2A & B

4

10% Limit (Divide Line 3 Column (a) By 9)

5

Total Computable - Allotment (Allotment Divided By The Enhanced FMAP)

6

10% Of The Allotment - Total Computable (10% Times Line 5)

7

10% Limit (Lesser Of Lines 4 Column (a) Or 6 Column (a))

8A

Expenditures Previously Claimed Under Section 2105(a)(2)

8B

Expenditures Currently Claimed Under Section 2105(a)(2)

9

Total Of Lines 8A And 8B

10

Amount Under/(Over) Limit (Line 7 Minus 9)

Form CMS 21 L

(B)

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 1998

(A)
(10/01/1997 - 09/30/1998)

1

FFY 1998 Allotment

2

First Quarter 1998

3

Second Quarter 1998

4

Third Quarter 1998

5

Fourth Quarter 1998

6

Excess 10% Limit

7

Unused Allotment

8

Excess Expenditures

FFY 1999

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(10/01/1998 - 09/30/1999)

1

Unused FFY 1998 Allotment

2

FFY 1999 Allotment

3
4

Excess Previously Claimed in
Prior Years
First Quarter 1999

5

Second Quarter 1999

6

Third Quarter 1999

7

Fourth Quarter 1999

8

Excess 10% Limit

9

Unused Allotment

10

Excess Expenditures

FFY 2000

1905(u)(2)/(3)

(10/01/1999 - 09/30/2000)

1

Unused FFY 1998 Allotment

2

Unused FFY 1999 Allotment

3

FFY 2000 Allotment

4
5

Excess Previously Claimed in
Prior Years
First Quarter 2000

6

Second Quarter 2000

7

Third Quarter 2000

8

Fourth Quarter 2000

9

Excess 10% Limit

10

Unused Allotment

11

Excess Expenditures

12

FFY 1998 Allotment Added to
Redistribution Pool

Form CMS 21C

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 2001
1

(A)
(10/01/2000 - 09/30/2001)

2

FFY 1998 Redistributed
Allotment
FFY 1998 Retained Amount

3

Unused FFY 1999 Allotment

4

Unused FFY 2000 Allotment

5

FFY 2001 Allotment

6
7

Excess Previously Claimed in
Prior Years
First Quarter 2001

8

Second Quarter 2001

9

Third Quarter 2001

10

Fourth Quarter 2001

11

Excess 10% Limit

12

Unused Allotment

13

Excess Expenditures

14

FFY 1999 Allotment added to
Redistribution Pool

FFY 2002
1

4
5

Unused FFY 2000 Allotment

6

Unused FFY 2001 Allotment

7

FFY 2002 Allotment

8
9

Excess Previously Claimed in
Prior Years
First Quarter 2002

10

Second Quarter 2002

11

Third Quarter 2002

12

Fourth Quarter 2002

13

Excess 10% Limit

14

Unused Allotment

15

Excess Expenditures

16

FFY 2000 Allotment added to
Redistribution Pool

3

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(10/01/2001 - 09/30/2002)

Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
FFY 1999 Redistributed
Allotment
FFY 1999 Retained Amount

2

1905(u)(2)/(3)

Form CMS 21C

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 2003
1

(A)
(10/01/2002 - 09/30/2003)

6

Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
Unused FFY 1999
Redistributed Allotment
Unused FFY 1999 Retained
Amount
FFY 2000 Redistributed
Amount
FFY 2000 Retained Allotment

7

Unused FFY 2001 Allotment

8

Unused FFY 2002 Allotment

9

FFY 2003 Allotment

10
11

Excess Previously Claimed in
Prior Years
First Quarter 2003

12

Second Quarter 2003

13

Third Quarter 2003

14

Fourth Quarter 2003

15

Excess 10% Limit

16

Unused Allotment

17

Excess Expenditures

18

FFY 2001 Allotment added to
Redistribution Pool

2
3
4
5

Form CMS 21C

1905(u)(2)/(3)

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 2004
1

(A)
(10/01/2003 - 09/30/2004)

8

Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
Unused FFY 1999
Redistributed Allotment
Unused FFY 1999 Retained
Amount
Unused FFY 2000
Redistributed Allotment
Unused FFY 2000 Retained
Amount
FFY 2001 Redistributed
Amount
FFY 2001 Retained Allotment

9

Unused FFY 2002 Allotment

10

Unused FFY 2003 Allotment

11

FFY 2004 Allotment

12
13

Excess Previously Claimed in
Prior Years
First Quarter 2004

14

Second Quarter 2004

15

Third Quarter 2004

16

Fourth Quarter 2004

17

Excess 10% Limit

18

Unused Allotment

19

Excess Expenditures

20

FFY 2002 Allotment added to
Redistribution Pool

2
3
4
5
6
7

Form CMS 21C

1905(u)(2)/(3)

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 2005
1

(A)
(10/01/2004 - 09/30/2005)

4

Unused FFY 2001
Redistributed Amount
Unused FFY 2001 Retained
Allotment
FFY 2002 Redistributed
Allotment
Unused FFY 2003 Allotment

5

Unused FFY 2004 Allotment

6

FFY 2005 Allotment

7
8

Excess Previously Claimed in
Prior Years
First Quarter 2005

9

Second Quarter 2005

10

Third Quarter 2005

11

Fourth Quarter 2005

12

Excess 10% Limit

13

Unused Allotment

14

Excess Expenditures

15

FFY 2003 Allotment added to
Redistribution Pool

2
3

FFY 2006
1

1905(u)(2)/(3)

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(10/01/2005 - 09/30/2006)

2

FFY 2003 Redistributed
Allotment
FFY 2006 Shortfall

3

Unused FFY 2004 Allotment

4

Unused FFY 2005 Allotment

5

FFY 2006 Allotment

6
7

Excess Previously Claimed in
Prior Years
First Quarter 2006

8

Second Quarter 2006

9

Third Quarter 2006

10

Fourth Quarter 2006

11

Excess 10% Limit

12

Unused Allotment

13

Excess Expenditures

14

FFY 2004 Allotment added to
Redistribution Pool

Form CMS 21C

Thursday, February 14, 2008 - 01:31 PM

OMB No. 0938-0731
Expires 6/30/2008

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:

Quarter Ended:
Federal Share Expenditures Only
Title XXI

Title XIX
20% Medicaid

FFY 2007
1

(A)
(10/01/2006 - 09/30/2007)

1905(u)(2)/(3)

PE

2105 (a)(1)(C)

2105(a)(1)(D)

Total

Balance

Unused

(B)

(C)

(D)

(E)

(F)

(G)

(H)

FFY 2004 Redistributed
Allotment
FFY 2005 Redistributed
Allotment
FFY 2007 Shortfall

2
3
4
5

Negative Adjustment FFY
2005 Allotment
Unused FFY 2005 Allotment

6

Unused FFY 2006 Allotment

7

FFY 2007 Allotment

8
9

Excess Previously Claimed in
Prior Years
First Quarter 2007

10

Second Quarter 2007

11

Third Quarter 2007

12

Fourth Quarter 2007

13

Excess 10% Limit

14

Unused Allotment

15

Excess Expenditures

16

FFY 2005 Allotment added to
Redistribution Pool

FFY 2008
1

(10/01/2007 - 09/30/2008)

2

FFY 2005 Redistributed
Allotment
Unused FFY 2006 Allotment

3

Unused FFY 2007 Allotment

4

FFY 2008 Allotment

5
6

Excess Previously Claimed in
Prior Years
First Quarter 2008

7

Second Quarter 2008

8

Third Quarter 2008

9

Fourth Quarter 2008

10

Excess 10% Limit

11

Unused Allotment

12

Excess Expenditures

13

FFY 2006 Allotment added to
Redistribution Pool

Form CMS 21C

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

State Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Covers:
Program Code:
Type of Waiver:
Waiver Name:
Waiver Number:

Quarter Ended:
Adults

1A

Premiums For Private Health Care Insurance Coverage: Up
To 150% Of Poverty Level - Gross Premiums Paid

1B

Premiums For Private Health Care Insurance Coverage: Up
To 150% Of Poverty Level - Cost Sharing Offsets

1C

Premiums For Private Health Care Insurance Coverage: Over
150% Of Poverty Level - Gross Premiums Paid

1D

Premiums For Private Health Care Insurance Coverage: Over
150% Of Poverty Level - Cost Sharing Offsets

2

Inpatient Hospital Services

3

Inpatient Mental Health Facility Services

4

Nursing Care Services

5

Physician And Surgical Services

6

Outpatient Hospital Services

7

Outpatient Mental Health Facility Services

8

Prescribed Drugs

9

Dental Services

10

Vision Services

11

Other Practitioners' Services

12

Clinic Services

13

Therapy Services

14

Laboratory And Radiological Services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions No. 0

18

Screening Services

19

Home Health

20

Reserved

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Services

26

Outreach

27

Administration

28

Balance

29

Less: Collections

30

Total

Form CMS-21 Waiver

Subject To 10% Limit
Total
Computable
(A)

Federal
Share
77.33%
(B)

Federal
Total

Computable
(C)

Share
77.33%
(D)

Total
Federal
Share
(E)

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 6/30/2008

State Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments
State:

Quarter Ended:
Fiscal Year:
Line:

Covers:
Program Code:

Adults

Type of Waiver:
Waiver Name:
Waiver Number:
1A

2

Premiums For Private Health Care Insurance Coverage: Up To
150% Of Poverty Level - Gross Premiums Paid
Premiums For Private Health Care Insurance Coverage: Up To
150% Of Poverty Level - Cost Sharing Offsets
Premiums For Private Health Care Insurance Coverage: Over
150% Of Poverty Level - Gross Premiums Paid
Premiums For Private Health Care Insurance Coverage: Over
150% Of Poverty Level - Cost Sharing Offsets
Inpatient Hospital Services

3

Inpatient Mental Health Facility Services

4

Nursing Care Services

5

Physician And Surgical Services

6

Outpatient Hospital Services

7

Outpatient Mental Health Facility Services

8

Prescribed Drugs

9

Dental Services

10

Vision Services

11

Other Pracitioners' Services

12

Clinic Services

13

Therapy Services

14

Laboratory And Radiological Services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions No. 0

18

Screening Services

19

Home Health

20

Reserved

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Services

26

Outreach

27

Administration

28

Balance

29

Less: Collections

30

Total

1B
1C
1D

Form CMS-21P Waiver

Subect To 10% Limit
Total
Computable
(A)

Federal
Share
0
(B)

Federal
Total

Computable
(C)

Share
0
(D)

Total
Federal
Share
(E)

Deferral
Disallowance
C.I.N. No.
(F)

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB NO 0938-0731

Provider-Related Donations And
Health Care Related Taxes, Fees, And Assessments
Received Under Public Law 102-234

Actual Receipts By Plan Name
State:

Quarter Ended:

CODES:
1.

Donations - Permissible (Bona Fide)

4.

Taxes - Permissible

7.

Fees - Impermissible

1.A.

Donations - Permissible (Bona Fide) - SCHIP Related

4.A.

Taxes - Permissible - SCHIP Related

7.A.

Fees - Impermissible - SCHIP Related

2.

Donations - Impermissible

5.

Taxes - Impermissible

8.

Assessments - Permissible

2.A.

Donations - Impermissible - SCHIP Related

5.A.

Taxes - Impermissible - SCHIP Related

8.A.

Assessments - Permissible - SCHIP Related

3.

Donations - Outstationed Eligibility Workers

6.

Fees - Permissible

9.

Assessments - Impermissible

3.A.

Donations - Outstationed Eligibility Workers - SCHIP
Related

6.A.

Fees - Permissible - SCHIP Related

9.A.

Assessments - Impermissible - SCHIP Related

Code

Plan Name

Receipts

(A)

(B)

(C)

Form CMS 21.11A

Thursday, February 14, 2008 - 01:31 PM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB NO 0938-0731

Provider-Related Donations And
Health Care Related Taxes, Fees, And Assessments
Received Under Public Law 102-234

Summary Total Of Receipts From Form CMS 21.11
State:

Quarter Ended:
Category

Total Receipts

(A)

(B)

Donations
1.

Donations-Permissible (Bona Fide)

2.

Donations-Impermissible

3.

Donations-Outstationed Eligibility Workers

Taxes
4.

Taxes-Permissible

5.

Taxes-Impermissible

Fees
6.

Fees - Permissible

7.

Fees - Impermissible

Assessments
8.

Assessments - Permissible

9.

Assessments - Impermissible

Totals
10.

Total Permissible Taxes, Fees, and Assessments (Lines 4+6+8)

11.

Total Impermissible Taxes, Fees, and Assessments (Lines 5+7+9)

Form CMS 21.11

Thursday, February 14, 2008 - 01:31 PM

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0731
Expires 6/30/2008

CHILDREN'S HEALTH INSURANCE PROGRAM EXPENDITURES
FOR THE TITLE XXI PROGRAM

APPLICATION OF 20% MEDICAID ALLOWANCE
FOR FY 2005 THRU 2008 ALLOTMENT STATES
USED IN THE CALCULATION OF 20% LIMIT

FEDERAL SHARE
20%
20%
20%
20%
MEDICAID FY MEDICAID FY MEDICAID FY MEDICAID FY
2005
2006
2007
2008
(A)

(B)

(C)

(D)

1 Beginning Balance
2 Allotment Remaining
3 Net Remaining Balance (Lesser of Line 1 or Line 2)
4 Currently Claimed SCHIP Expenditures in Fiscal Year
5 Ending Balance (Line 3 Minus Line 4)
6 Other SCHIP Expenditures claimed this quarter (From 21C,
Columns B, C, D and E)
7 Allotment remaining at end of quarter (From 21C, Column
H)
8 20% Allowance balance at end of quarter (Lesser of Lines
5 or 7)

FORM CMS-21T TRACKING

Thursday, February 14, 2008 - 01:31 PM