| Department of Health and Human Services |
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OMB No. 0938-0101 |
| Centers for Medicare & Medicaid Services |
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| Medicaid Program Budget Report |
| Variances in Certification Quarter Estimate From Recent Expenditures |
| Medical Assistance, Medicaid SCHIP Expansions and State and Local Administration |
| (Total Computable Dollars in Thousands) |
| State: |
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Submission Date: |
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Medical Assistance Payments |
Medicaid SCHIP |
State and Local Administration |
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A |
B |
C |
| Estimate |
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| 1. Certification Quarter |
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| 2. Most Recent Expenditure Quarter |
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| 3. Same Quarter Previous FY |
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| Certification Quarter Variances |
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| 4. From Most Recent Expenditure Quarter |
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| A. Amount Variance |
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| B. Percent Variance |
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| 5. From Same Quarter Previous FY |
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| A. Amount Variance |
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| B. Percent Variance |
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| Form CMS-37.1V |
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Report Date: |