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

(CMS-10529) Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (MBES/CBES Forms CMS-21 and -21B, -37, and -64)

OMB: 0938-1265

IC ID: 213566

Information Collection (IC) Details

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Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and CMS-21B)
 
No Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-21 Quarterly Children’s 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
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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 224 0 0 0 0 224
Annual IC Time Burden (Hours) 4,480 0 0 0 0 4,480
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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