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

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21 Summary - Quarterly Children's Health Insurance Program
Statement of Expenditures for Title XXI
Summary Sheet
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Expenditures In This Quarter (Form CMS 21
Base)
1
Adjustments Increasing Claims For Prior
Quarters (Form CMS 21P)
2
Adjustments Decreasing Claims For Prior
Quarters (Form CMS 21P)
3
Adjustments Decreasing Claims - Collections
4
Adjustments Decreasing Claims - MEQC
Collections
4A
Adjustments/Decreasing Claims - Perm (Form
CMS 21Perm)
5
Adjustments - Decreasing Claims Overpayments
6
Adjustments - Decreasing Claims -MEQC
Overpayments
6A
Net Expenditures Reported In This Period
7

Form CMS 21 Summary

Federal Share

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21 Base - Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2023

Line #
1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
31
32
32A
32B
33
34
35
35A
35B
50

Total
Line Description
Computable
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offsets
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums Over 150% Of Poverty Level - Cost
Sharing Offsets
Inpatient Hospital Services
Inpatient Mental Health Facility Services
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Health Services Initiatives
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Outreach

10% Limit:
Total
Federal Share Computable

10% Limit:
Total Federal
Federal Share Share

Increased Outreach and Enrollment of Indians
Increase Outreach and Enrollment of children
through premium subsidies
Administration
PERM Administration
Citizenship Verification Technology-CHIPRA
CVT Development
CVT Operation
Total

Form CMS 21 Base

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21 - Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures by Quarter
State:
Quarter Ended: 12/31/2023
Program:

Line #
1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
31
32
32A
32B
33
34
35
35A
35B
50

Form CMS 21

Line Description
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offsets
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums Over 150% Of Poverty Level - Cost
Sharing Offsets
Inpatient Hospital Services
Inpatient Mental Health Facility Services
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Health Services Initiatives
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Outreach

Total
Computable

10% Limit:
Total
Federal Share Computable

10% Limit:
Total Federal
Federal Share Share

Increased Outreach and Enrollment of Indians
Increase Outreach and Enrollment of children
through premium subsidies
Administration
PERM Administration
Citizenship Verification Technology-CHIPRA
CVT Development
CVT Operation
Total

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21P - Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Program:

Line #
1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
31
32
32A
32B
33
34
35
35A
35B
50

Total
Line Description
Computable
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost
Sharing Offsets
Premiums Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums Over 150% Of Poverty Level - Cost
Sharing Offsets
Inpatient Hospital Services
Inpatient Mental Health Facility Services
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Pracitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Health Services Initiatives
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Outreach

10% Limit:
Total
Federal Share Computable

Deferral
10% Limit:
Total Federal Disallowance
Federal Share Share
C.I.N. No.

Increased Outreach and Enrollment of Indians
Increase Outreach and Enrollment of children
through premium subsidies
Administration
PERM Administration
Citizenship Verification Technology-CHIPRA
CVT Development
CVT Operation
Total

Form CMS 21.P

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21L - Children's Health Insurance Program Expenditures
For the Title XXI Program
Calculation of 10% Limit
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Computable
Previously Claimed Expenditures - Section
2105(a)(1)(C)
1A
Previously Claimed Expenditures - Section
2105(a)(1)(A)
1B
Expenditures Claimed In The Current Quarter Section 2105(a)(1)(C)
2A
Expenditures Claimed In The Current Quarter Sections 2105(a)(1)(A)
2B
Total Of Column (a) Lines 1A & B And 2A & B
3
10% Limit (Divide Line 3 Column (a) By 9)
4
Total Computable - Allotment (Allotment
Divided By The CHIP Rate)
5
10% Of The Allotment - Total Computable (10%
Times Line 5)
6
10% Limit (Lesser Of Lines 4 Column (a) Or 6
Column (a))
7
Expenditures Previously Claimed Under Section
2105(a)(2)
8A
HSI Previously Claimed under Section
2105(a)(2)
8A1
Expenditures Currently Claimed Under Section
2105(a)(2)
8B
8B1
9
9A
9B
9C
9D
9E
9F
10

Federal Share

HSI Currently Claimed under Section 2105(a)(2)
Total - Lines 8.A., 8.A.1, 8.B. and 8.B.1
Expenditures Previously Claimed for Outreach
to Children (Line 32B of 21)
Expenditures Currently claimed for Outreach to
Children (Line 32B of 21)
Total of lines 9A and 9B
Outreach and enrollment for children 1.25% of
10% limit of allotment (Line 6)
Expenditures for children outreach (9C) minus
Outreach allotment (9D)
Total - Lines 8.A., 8.A.1, 8.B., 8.B.1 and 9E
Amount Under/(Over) Limit (Line 7 Minus 9F)

Form CMS 21.L

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21L OA - Children's Health Insurance Program Expenditures
For the Title XXI Program
State:
Quarter Ended: 12/31/2023

Line #
1
2
3
4

5
6

7
8
9
10
11

12
13
14
15
16

Line Description
Beginning Balance
Previously Claimed Sections 1905(u)(2) and
1905(u)(3) M-CHIP Expenditures in Fiscal Year
Previously Claimed Section 1920A
Expenditures in Fiscal Year
Previously Claimed Section 2105(a)(1)(C) CHIP
Expenditures in Fiscal Year
Previously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Net of Outreach &
Admin
Previously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Outreach

Retained
Allotment and
Expenditure
Amounts

Remaining
Outreach
Allowance or
Expenditure
Amount

Fed Share of
Outreach
Expend Subj.
to 10% FY
Limit

Tot. Comp of
Outreach
Expend Subj.
to 10% FY
Limit

Previously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Administration
Balance From Previous Quarter
Currently Claimed Sections 1905(u)(2) and
1905(u)(3) M-CHIP Expenditures in Fiscal Year
Currently Claimed Section 1920A Expenditures
in Fiscal Year
Currently Claimed Section 2105(a)(1)(C) CHIP
Expenditures in Fiscal Year
Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Net of Outreach &
Admin
Balance
Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Outreach
Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Administration
Net

Form CMS 21L OA

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21C - Allocation of Title XIX and Title XXI Expenditures
To CHIP Fiscal Year Amount
State:
Quarter Ended: 12/31/2023

Line #

Line Description

Qualifying
State

Title XIX - Sec.
1905
Title XIX - PE

Title XXI - Sec. Title XXI - Sec.
2105(a)(1)
2105(a)(2)
Total

Balance

Unused

Fiscal Year: 2020
FFY 2018 and prior Redistributed Allotment
1
Unused FFY 2019 Allotment
2
FFY 2020 Allotment
3
First Quarter 2020
4
Second Quarter 2020
5
Third Quarter 2020
6
Fourth Quarter 2020
7
Excess 10% Limit
8
Unused Allotment
9
Excess Expenditures
10
FFY 2019 Allotment added to Redistribution Pool
11
Fiscal Year: 2021
FFY 2019 and prior Redistributed Allotment
1
Unused FFY 2020 Allotment
2
FFY 2021 Allotment
3
First Quarter 2021
4
Second Quarter 2021
5
Third Quarter 2021
6
Fourth Quarter 2021
7
Excess 10% Limit
8
Unused Allotment
9
Excess Expenditures
10
FFY 2020 Allotment added to Redistribution Pool
11
Fiscal Year: 2022
FFY 2020 and prior Redistributed Allotment
1
Unused FFY 2021 Allotment
2
FFY 2022 Allotment
3
First Quarter 2022
4
Second Quarter 2022
5
Third Quarter 2022
6
Fourth Quarter 2022
7
Excess 10% Limit
8
Unused Allotment
9
Excess Expenditures
10
FFY 2021 Allotment added to Redistribution Pool
11
Fiscal Year: 2023
FFY 2021 and prior Redistributed Allotment
1
Unused FFY 2022 Allotment
2
FFY 2023 Allotment - Section 3002
3
FFY 2023 Allotment - Section 2104(a)(26)(A)
4
FFY 2023 Allotment - Section 2104(a)(26)(B)
5
First Quarter 2023
6
Second Quarter 2023
7
Third Quarter 2023
8
Fourth Quarter 2023
9
Excess 10% Limit
10
Unused Allotment
11
Excess Expenditures
12
FFY 2022 Allotment added to Redistribution Pool
13
Fiscal Year: 2024
FFY 2022 and prior Redistributed Allotment
1
Unused FFY 2023 Allotment
2
FFY 2024 Allotment
3
Excess Previously Claimed in Prior Years
4
First Quarter 2024
4
First Quarter 2024
5
Second Quarter 2024
5
Second Quarter 2024
6
Third Quarter 2024
6
Fourth Quarter 2024
7
Third Quarter 2024
7
Excess 10% Limit
8
Fourth Quarter 2024
8
Excess 10% Limit
9
Unused Allotment
9
Excess Expenditures
10
Unused Allotment
10
Excess Expenditures
11
FFY 2023 Allotment added to Redistribution Pool
11
FFY 2023 Allotment added to Redistribution Pool
12

Form CMS 21.C

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21WAIVER - Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2023
Waiver Type:
Waiver Number:
Waiver Name:
Program:

Line #

Line Description

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
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
31
32
32A
32B
33
34
35
35A
35B
50

Total
Computable

10% Limit:
Total
Federal Share Computable

10% Limit:
Total Federal
Federal Share Share

Premiums For Private Health Care Insurance Coverage:
Over 150% Of Poverty Level - Cost Sharing Offsets
Inpatient Hospital Services
Inpatient Mental Health Facility Services
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Health Services Initiatives
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Outreach
Increased Outreach and Enrollment of Indians
Increase outreach and enrollment of children through
premium subsidies
Administration
PERM Administration
Citizenship Verification Technology-CHIPRA
CVT Development
CVT Operation
Total

Form CMS 21 Waiver

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21PWAIVER - Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2023
Prior Qtr/FYR:
Line:
Waiver Type:
Waiver Number:
Waiver Name:
Program:

Line #

1A

1B

1C

1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
31
32
32A
32B
33
34
35
35A
35B
50

Line Description
Premiums For Private Health Care Insurance
Coverage: Up To 150% Of Poverty Level Gross Premiums Paid
Premiums For Private Health Care Insurance
Coverage: Up To 150% Of Poverty Level - Cost
Sharing Offsets
Premiums For Private Health Care Insurance
Coverage: Over 150% Of Poverty Level - Gross
Premiums Paid
Premiums For Private Health Care Insurance
Coverage: Over 150% Of Poverty Level - Cost
Sharing Offsets
Inpatient Hospital Services
Inpatient Mental Health Facility Services
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Pracitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Health Services Initiatives
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
ARP Section 9821 COVID Vaccine/Vaccine
Administration
Other Services
Outreach

Total
Computable

10% Limit:
Total
Federal Share Computable

Deferral
10% Limit:
Total Federal Disallowance
Federal Share Share
C.I.N. No.

Increased Outreach and Enrollment of Indians
Increase Outreach and Enrollment of children
through premium subsidies
Administration
PERM Administration
Citizenship Verification Technology-CHIPRA
CVT Development
CVT Operation
Total

Form CMS 21.P Waiver

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21.11 - Summary of Total Receipts from Form CMS 21.11A
Provider-Related Donations and Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
State:
Quarter Ended: 12/31/2023
Code

Plan Name

Receipts

No data submitted for this form

Form CMS 21.11A

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21.11 - Actual Receipts by Plan Name
Provider-Related Donations and Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Total Receipts
Donations
Donations - General
1
Donations- Outstationed Eligibility Workers Specific
2
Taxes
Taxes
3
Fees
Fees
4
Assessments
Assessments
5
Totals
Total Donations (Lines 1 + 2)
6
Total Taxes, Fees, and Assessments (Lines 3 + 4
+ 5)
7

Form CMS 21.11

0
0
0
0
0
0
0

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21 PERM - Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustment PERM
State:
Quarter Ended: 12/31/2023
Line #

1
2
3

4
5

Line Description
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The
60-Day Time Limit
Decreasing Adjustments To Amounts
Previously Reported On Line 1
Subtotal
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt
Or Out Of Business
Total Overpayment Adjustments This Quarter

Form CMS 21 Perm

Total
Computable

2021 And
Prior

2022

2023

2024

Total Federal
Share

Report Date: Thursday, February 01, 2024 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form CMS 21T.Track - Children's Health Insurance Program Expenditures
For the Title XXI Program
State:
Quarter Ended: 12/31/2023
Line #
Line Description
Medicaid FY 2021
Beginning Balance
1
Allotment Remaining
2
Net Remaining Balance (Lesser of Line 1 or
Line 2)
3
Currently Claimed CHIP Expenditures in Fiscal
Year
4
Ending Balance (Line 3 Minus Line 4)
5
Other CHIP Expenditures claimed this quarter
(From 21C, Columns B, C, D and E)
6
Allotment remaining at end of quarter (From
21C, Column H)
7
Allowance balance at end of quarter (Lesser of
Lines 5 or 7)
8

Form CMS 21T Tracking

OMB No. 0938-1265
Expires 4/30/2024

Medicaid FY 2022

Medicaid FY 2023

Not Applicable

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21O - Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustments
State:
Quarter Ended: 12/31/2023
Line #

1
2
3

4
5

Line Description
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The
60-Day Time Limit
Decreasing Adjustments To Amounts
Previously Reported On Line 1
Subtotal
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt
Or Out Of Business
Total Overpayment Adjustments This Quarter

Form CMS 21.O

Total
Computable

2021 And
Prior

2022

2023

2024

Total Federal
Share

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Form CMS 21OMEQC - Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustments - MEQC
State:
Quarter Ended: 12/31/2023
Line #

1
2
3

4
5

Line Description
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The
60-Day Time Limit
Decreasing Adjustments To Amounts
Previously Reported On Line 1
Subtotal
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt
Or Out Of Business
Total Overpayment Adjustments This Quarter

Form CMS 21.OMEQC

Total
Computable

2021 And
Prior

2022

2023

2024

Total Federal
Share

Report Date: Thursday, February 01, 2024 - 12:00 AM

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

OMB No. 0938-1265
Expires 4/30/2024

Medicaid Program Expenditure Report
Other Narrative Explanations
State:
Quarter Ended: 12/31/2023
Narrative

Form CMS 21 Narrative

Report Date: Thursday, February 01, 2024 - 12:00 AM