Information Collection

Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)

IC 213566 under ICR 201901-0938-004 · OMB 0938-1265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1265 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-21B Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B) Form and Instruction
CMS-21 Quarterly Children’s Health Insurance Program Statement 21 Summary and 21 O MEQC.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx Form and Instruction
CMS-21B Children's Health Insurance Program Budget Report for th 21B Blank Form.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx Form and Instruction
Crosswalk for CMS-21 and CMS-64 (version 2).docx Crosswalk (CMS-21 Summary) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-21B	Children's Health Insurance Program Budget Report for the Title XXI	21B Blank Form.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-21	Quarterly Childrenâs Health Insurance Program Statement of Expenditures for Title XXI	21 Summary and 21 O MEQC.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	4,480	4,480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk (CMS-21 Summary)	Crosswalk for CMS-21 and CMS-64 (version 2).docx	03/22/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.