Form CMS-21 Quarterly Children’s Health Insurance Program Statement

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by
Type of Service for the Title XXI Program
Expenditures in this Quarter

State:

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

Adjustments Decreasing Claims - Collections

5

Adjustments/Decreasing Claims - Perm (Form CMS 21Perm)

6

Adjustments - Decreasing Claims - Overpayments

7

Net Expenditures Reported In This Period

Quarter Ended:

Title XXI Expenditures

Expenditures Reported for Period

1

OMB No. 0938-1265
Expires 12/31/2017

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 Children’s Health Insurance Program (CHIP) under Title XXI of the Act that
are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, policies, and the
Children 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 Children 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

Report Date: Wednesday, September 13, 2017 -

Department of Health and Human Services Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

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

State:

Federal Share
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

8A

Drug Rebate

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

Health Services Initiatives

Form CMS 21 Base

%

Subject To 10% Limit
Federal Share
Total
Computable

(B)

(C)

%

(D)

Total Federal
Share

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

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

State:

Federal Share
Total
Computable

(A)
21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Translation and Interpretation (FFP Rate 75%)

31

Other Services

32

Outreach

32A

Increased Outreach and Enrollment of Indians

32B

Increase Outreach and Enrollment of children through
premium subsidies

33

Administration

34

PERM Administration (FFP Rate 90%)

35

Citizenship Verification Technology-CHIPRA

35A

CVT Development (FFP Rate 90%)

35B

CVT Operation (FFP Rate 75%)

50

Total

Form CMS 21 Base

%

Subject To 10% Limit
Federal Share
Total
Computable

(B)

(C)

%

(D)

Total Federal
Share

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

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

State:

Program Code:

Federal Share
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

8A

Drug Rebate

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

Health Services Initiatives

Form CMS 21

%

Subject To 10% Limit
Federal Share
Total
Computable

(B)

(C)

%

(D)

Total Federal
Share

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

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

State:

Program Code:

Federal Share
Total
Computable

(A)
21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Translation and Interpretation (FFP Rate 75%)

31

Other Services

32

Outreach

32A

Increased Outreach and Enrollment of Indians

32B

Increase Outreach and Enrollment of children through
premium subsidies

33

Administration

34

PERM Administration (FFP Rate 90%)

35

Citizenship Verification Technology-CHIPRA

35A

CVT Development (FFP Rate 90%)

35B

CVT Operation (FFP Rate 75%)

50

Total

Form CMS 21

%

Subject To 10% Limit
Federal Share
Total
Computable

(B)

(C)

%

(D)

Total Federal
Share

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
State:
Line:

Subject To 10% Limit
Program Code:
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

8A

Drug Rebate

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

Form CMS 21P

Federal
Share
%

(B)

Total
Computable

(C)

Federal Share
%

(D)

Total
Federal
Share

Deferral
Disallow ance
C.I.N.No.

(E)

(F)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
State:
Line:

Subject To 10% Limit
Program Code:

Total
Computable

(A)
20

Health Services Initiatives

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Translation and Interpretation (FFP Rate 75%)

31

Other Services

32

Outreach

32A

Increased Outreach and Enrollment of Indians

32B

Increase Outreach and Enrollment of children through premium
subsidies

33

Administration

34

PERM Administration (FFP Rate 90%)

35

Citizenship Verification Technology-CHIPRA

35A

CVT Development (FFP Rate 90%)

35B

CVT Operation (FFP Rate 75%)

50

Total

Form CMS 21P

Federal
Share
%

(B)

Total
Computable

(C)

Federal Share
%

(D)

Total
Federal
Share

Deferral
Disallow ance
C.I.N.No.

(E)

(F)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by
Type of Service for the Title XXI Program
State:

1A

Prev iously Claimed Expenditures - Section 2105(a)(1)(C)

1B

Prev iously Claimed Expenditures - Section 2105(a)(1)(A)

2A

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

2B

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

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 CHIP Rate)

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)

8A1

HSI Prev iously Claimed under Section 2105(a)(2)

8B

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

8B1

HSI Currently Claimed under Section 2105(a)(2)

9

Total - Lines 8.A., 8.A.1, 8.B. and 8.B.1

9A

Expenditures Previously Claimed for Outreach to Children (Line 32B of 21)

9B

Expenditures Currently claimed for Outreach to Children (Line 32B of 21)

9C

Total of lines 9A and 9B

9D

Outreach and enrollment for children 1.25% of 10% limit of allotment (Line 6)

9E

Expenditures for children outreach (9C) minus Outreach allotment (9D)

9F

Total - Lines 8.A., 8.A.1, 8.B., 8.B.1 and 9E

10

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

Form CMS 21L

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Total Computable

Federal Share

(A)

(B)

Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017

Type of Service for the Title XXI Program
State:
Application of 10% Outreach Allow ance For FY
For FY 1998 Retained Allotm ent States
Used in the Calculation of 10% Fiscal Year Lim it

Quarter Ended: 06/30/2017
Retained
Allotment and
Expenditure
Amounts

(A)
1

Beginning Balance

2

Prev iously Claimed Sections 1905(u)(2) and 1905(u)(3)
M-CHIP Expenditures in Fiscal Y ear

3

Prev iously Claimed Section 1920A Expenditures in
Fiscal Y ear

4

Prev iously Claimed Section 2105(a)(1)(C) CHIP
Expenditures in Fiscal Y ear

5

Prev iously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Net of Outreach & Admin

6

Prev iously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Outreach

7

Prev iously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Administration

8

Balance From Prev ious Quarter

9

Currently Claimed Sections 1905(u)(2) and 1905(u)(3)
M-CHIP Expenditures in Fiscal Y ear

10

Currently Claimed Section 1920A Expenditures in
Fiscal Y ear

11

Currently Claimed Section 2105(a)(1)(C) CHIP
Expenditures in Fiscal Y ear

12

Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Net of Outreach & Admin

13

Balance

14

Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Outreach

15

Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Y ear - Administration

16

Net

Form CMS 21L Outreach Allowance

Remaining Outreach
Federal Share of
Allow ance or
Outreach
Expenditure
Expenditures Subject
Amounts
To 10% FY Limit

(B)

(C)

Total Computable
Share of Outreach
Subject To 10% FY
Limit

(D)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by
Type of Service for the Title XXI Program
Expenditures in this Quarter

State:

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Federal Share Expenditures Only
Title XIX

Title XXI

Qualif y ing State

1905(u)(2)(3)

PE

(A)

(B)

(C)

2105(a)(1)(C) 2105(a)(1)(D)
(D)

(E)

Total

Balance

Unused

(F)

(G)

(H)

FFY 2013 (10/01/2012 - 09/30/2013)
1

FFY 2011 and prior Redistributed
Allotment

2

Unused FFY 2012 Allotment

3

FFY 2013 Allotment

4

First Quarter 2013

5

Second Quarter 2013

6

T hird Quarter 2013

7

Fourth Quarter 2013

8

Excess 10% Limit

9

Unused Allotment

10

Excess Expenditures

11

FFY 2012 Allotment added to
Redistribution Pool

FFY 2014 (10/01/2013 - 09/30/2014)
1

FFY 2012 and prior Redistributed
Allotment

2

Unused FFY 2013 Allotment

3

FFY 2014 Allotment

4

First Quarter 2014

5

Second Quarter 2014

6

T hird Quarter 2014

7

Fourth Quarter 2014

8

Excess 10% Limit

9

Unused Allotment

10

Excess Expenditures

11

FFY 2013 Allotment added to
Redistribution Pool

Form CMS 21 C

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:

Federal Share Expenditures Only
Title XIX

Title XXI

Qualif y ing State

1905(u)(2)(3)

PE

(A)

(B)

(C)

2105(a)(1)(C) 2105(a)(1)(D)
(D)

(E)

Total

Balance

Unused

(F)

(G)

(H)

FFY 2015 (10/01/2014 - 09/30/2015)
1

FFY 2013 and prior Redistributed
Allotment

2

Unused FFY 2014 Allotment

3

FFY 2015 Allotment - Section 108

4

FFY 2015 Allotment - Section
2104(a)(18)(A)

5

FFY 2015 Allotment - Section
2104(a)(18)(B)

6

First Quarter 2015

7

Second Quarter 2015

8

T hird Quarter 2015

9

Fourth Quarter 2015

10

Excess 10% Limit

11

Unused Allotment

12

Excess Expenditures

13

FFY 2014 Allotment added to
Redistribution Pool

FFY 2016 (10/01/2015 - 09/30/2016)
1

FFY 2014 and prior Redistributed
Allotment

2

Unused FFY 2015 Allotment Section 108

3

Unused FFY 2015 Allotment Section 2104(a)(18)(A)

4

Unused FFY 2015 Allotment Section 2104(a)(18)(B)

5

FFY 2016 Allotment

6

First Quarter 2016

7

Second Quarter 2016

8

T hird Quarter 2016

9

Fourth Quarter 2016

10

Excess 10% Limit

11

Unused Allotment

12

Excess Expenditures

13

FFY 2015 Allotment added to
Redistribution Pool

Form CMS 21 C

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:

Federal Share Expenditures Only
Title XIX

Title XXI

Qualif y ing State

1905(u)(2)(3)

PE

(A)

(B)

(C)

2105(a)(1)(C) 2105(a)(1)(D)
(D)

(E)

Total

Balance

Unused

(F)

(G)

(H)

FFY 2017 (10/01/2016 - 09/30/2017)
1

FFY 2015 and prior Redistributed
Allotment

2

Unused FFY 2016 Allotment

3

FFY 2017 Allotment - Section 301

4

FFY 2017 Allotment - Section
2104(a)(20)(A)

5

FFY 2017 Allotment - Section
2104(a)(20)(B)

6

First Quarter 2017

7

Second Quarter 2017

8

T hird Quarter 2017

9

Fourth Quarter 2017

10

Excess 10% Limit

11

Unused Allotment

12

Excess Expenditures

13

FFY 2016 Allotment added to
Redistribution Pool

Form CMS 21 C

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:
Covers:
Program Code:
Waiver Type:

Federal Share
Total
Computable

%

Subject To 10% Limit
Federal Share
Total
Computable

%

Total Federal
Share

Waiver Nam e:
Waiver Num ber:

(A)
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

8A

Drug Rebate

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

Health Services Initiatives

Form CMS 21 Waiver

(B)

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:
Covers:
Program Code:
Waiver Type:

Federal Share
Total
Computable

%

Subject To 10% Limit
Federal Share
Total
Computable

%

Total Federal
Share

Waiver Nam e:
Waiver Num ber:

(A)
21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Translation and Interpretation (FFP Rate 75%)

31

Other Services

32

Outreach

32A

Increased Outreach and Enrollment of Indians

32B

Increase outreach and enrollment of children through
premium subsidies

33

Administration

34

PERM Administration (FFP Rate 90%)

35

Citizenship Verification Technology-CHIPRA

35A

CVT Development (FFP Rate 90%)

35B

CVT Operation (FFP Rate 75%)

50

Total

Form CMS 21 Waiver

(B)

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:
Line:

Subject To 10% Limit

Covers:
Program Code:
Waiver Type:
Waiver Nam e:
Waiver Num ber:
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

8A

Drug Rebate

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

Form CMS 21P Waiver

Total
Computable

(A)

Federal
Share
%

(B)

Total
Computable

(C)

Federal Share
%

(D)

Total
Federal
Share

Deferral
Disallow ance
C.I.N.No.

(E)

(F)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Expenditures by

OMB No. 0938-1265
Expires 12/31/2017
Quarter Ended:

Type of Service for the Title XXI Program
Expenditures in this Quarter

State:
Line:

Subject To 10% Limit

Covers:
Program Code:
Waiver Type:
Waiver Nam e:
Waiver Num ber:
20

Health Services Initiatives

21

Home And Community-Based Services

22

Hospice

23

Medical Transportation

24

Case Management

25

Translation and Interpretation (FFP Rate 75%)

31

Other Services

32

Outreach

32A

Increased Outreach and Enrollment of Indians

32B

Increase Outreach and Enrollment of children through premium
subsidies

33

Administration

34

PERM Administration (FFP Rate 90%)

35

Citizenship Verification Technology-CHIPRA

35A

CVT Development (FFP Rate 90%)

35B

CVT Operation (FFP Rate 75%)

50

Total

Form CMS 21P Waiver

Total
Computable

(A)

Federal
Share
%

(B)

Total
Computable

(C)

Federal Share
%

(D)

Total
Federal
Share

Deferral
Disallow ance
C.I.N.No.

(E)

(F)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Provider-Related Donations and Health
Care Related Taxes, Fees, and
Received Under Public Law 102-234
Actual Receipts by Plan Name
CODE:

4. Fees
5. Assessments

1. Donations - General
2. Donations- Out stationed Eligibility Workers Specific
3. Taxes
Code
(A)

Form CMS 21.11A

Plan Name
(B)

Receipts
(C)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Provider-Related Donations and Health
Care Related Taxes, Fees, and
Received Under Public Law 102-234
Actual Receipts by Plan Name
CODE:

4. Fees
5. Assessments

1. Donations - General
2. Donations- Out stationed Eligibility Workers Specific
3. Taxes
Code
(A)

Form CMS 21.11A

Plan Name
(B)

Receipts
(C)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Provider-Related Donations and Health
Care Related Taxes, Fees, and
Received Under Public Law 102-234
Actual Receipts by Plan Name
CODE:

4. Fees
5. Assessments

1. Donations - General
2. Donations- Out stationed Eligibility Workers Specific
3. Taxes
Code
(A)

Form CMS 21.11A

Plan Name
(B)

Receipts
(C)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

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

OMB No. 0938-1265
Expires 12/31/2017

Provider-Related Donations and
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Summary Total of Receipts From Form CMS 21.11 A
State:
Plan Name

Receipts

(A)

(B)

Donations
1.
2.
Taxes

Donations - General
Donations- Outstationed Eligibility Workers - Specific

3.
Fees

Taxes

4.
Fees
Assessments
5.
Totals
6.
7.

Assessments

Total Donations (Lines 1 + 2)
Total Taxes, Fees, and Assessments (Lines 3 + 4 + 5)

Form CMS 21.11

Report Date: Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

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

Children's Health Expenditures
for the Title XXI Program
Overpayment Adjustment PERM
State:

Quarter Ended:
Federal Share

Total
Computable
PERM Activity
(A)

Total

PERM-identified Overpayments
FY

FY

FY

FY

(B)

(C)

(D)

(E)

Federal
(J)

1 Overpayments Not Collected Or Adjusted
But Refunded Because Of The Expiration
Of The 60-Day Time Limit

2 Decreasing Adjustments To Amounts
Previously Reported On Line 1

3 Subtotal

4 Previously Reported Overpayments To
Providers Certified This Quarter As
Bankrupt Or Out Of Business

5 Total Overpayment Adjustments This
Quarter

Form CMS 21 PERM

Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

Department of Health and Human Services Centers for Medicare & Medicaid Services
Children's Health Insurance Program Expenditures
for The Title XXI Program
State:

Quarter Ended:
Federal Share

Application of Medicaid Qualifying State
Allowance For FY 2014 Thru 2016

1

Beginning Balance

2

Allotment Remaining

3

Net Remaining Balance (Lesser of Line 1 or Line 2)

4

Currently Claimed CHIP Expenditures in Fiscal Y ear

5

Ending Balance (Line 3 Minus Line 4)

6

Other CHIP Expenditures claimed this quarter (From 21C,
Columns B, C, D and E)

7

Allotment remaining at end of quarter (From 21C, Column H)

8

Allowance balance at end of quarter (Lesser of Lines 5 or 7)

Form CMS 21T Tracking

20%
Medicaid FY
2014
(A)

20%
Medicaid FY
2015
(B)

Medicaid FY
2016
(C)

Not Applicable
(D)

Report Date: Wednesday, September 13, 2017 - 09:25 AM

OMB No. 0938-1265
Expires 12/31/2017

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

Children's Health Expenditures
for the Title XXI Program
Overpayment Adjustments

Quarter Ended:

State: Alabama

Total

Federal Share

Total

Computable

FY

FY

FY

FY

Federal

(A)

(B)

(C)

(D)

(E)

(J)

Overpayment Activity
1 Overpayments Not Collected Or Adjusted
But Refunded Because Of The Expiration
Of The 60-Day Time Limit

2 Decreasing Adjustments To Amounts
Previously Reported On Line 1

3 Subtotal

4 Previously Reported Overpayments To
Providers Certified This Quarter As
Bankrupt Or Out Of Business

5 Total Overpayment Adjustments This
Quarter

Form CMS 21.O

Wednesday, September 13, 2017 - 09:25 AM

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

State:

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Program Expenditure Report
Other Narrative Explanations

Quarter Ended:

Narrative

Form CMS 21 Narrative

Report Date: Wednesday, September 13, 2017 - 09:25 AM