CMS-21B State Children's Health Insurance Program Budget Report

Department of Health & Human Services

Form Approved

Centers for Medicare & Medicaid Services

OMB No. 0938-0731

State Children's Health Insurance Program Budget Report
For the Title XXI Program
State Expenditure Plan
(In Thousands)
Program:
Total Computable
Federal Share
Fiscal Year and
A
B
Quarter

State:
Submission Date:
Quarter Ended:

State Share
C

Fiscal Year: 2008
1. Quarter 1
2. Quarter 2
3. Quarter 3
4. Quarter 4
5. Total
Fiscal Year 2009
6. Quarter 1
7. Quarter 2
8. Quarter 3
9. Quarter 4
10. Total
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. The fiscal year budget estimates only include expenditures under the State Children’s Health Insurance Program (SCHIP) under Title XXI of the Social Security Act (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 during the fiscal year under Title XXI of the Act.
3. The budget estimates are based upon the most reliable information available to the state.
4. The state and/or local funds required to match the state’s allowable expenditures during the certification quarter will be available, and such state and/or local funds are in
accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. Federal matching funds are not being requested for the certification quarter to match expenditures under a state Child Health Plan amendment under Title XXI of the Act that was
submitted after January 2, 2001, and has not been approved by the Secretary effective for the certification quarter.
6. The information shown on the Form CMS-21B is correct to the best of my knowledge and belief.

Date:

Signature:

Title:

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-21B

Thursday, February 14, 2008 - 01:33 PM

Department of Health & Human Services

Form Approved

Centers for Medicare & Medicaid Services

OMB No. 0938-0731

State Children's Health Insurance Program Budget Report
For the Title XXI Program
State Expenditure Plan
(In Thousands)
Program:
Total Computable
Federal Share
Fiscal Year and
A
B
Quarter

State:
Submission Date:
Quarter Ended:

State Share
C

Fiscal Year: 2008
1. Quarter 1
2. Quarter 2
3. Quarter 3
4. Quarter 4
5. Total
Fiscal Year 2009
6. Quarter 1
7. Quarter 2
8. Quarter 3
9. Quarter 4
10. Total
Date:

Signature:

Title:

Footnotes:

Form CMS-21B

Thursday, February 14, 2008 - 01:33 PM