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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
Children's Health Insurance Program Budget Report
For the Title XXI Program State
Expenditure Plan
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
State:
Fiscal Year and Quarter
Total Computable
Federal Share
State Share
(A)
(B)
(C)
Fiscal Year:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
Fiscal Year:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
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. The fiscal year budget estimates only include expenditures under the Children’s Health Insurance Program (CHIP) under Title XXI of the
Social Security Act (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 during the fiscal year under Title XXI of the Act.
3. The budget estimates are based upon the most reliable information available to the state.
4. The state and/or local funds required to match the state’s allowable expenditures during the certification quarter will be available, and
such state and/or local funds are in accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. Federal matching funds are not being requested for the certification quarter to match expenditures under a Children Health Plan
amendment under Title XXI of the Act that was submitted after January 2, 2001, and has not been approved by the Secretary effective for
the certification quarter.
6. The information shown on the Form CMS-21B is correct to the best of my knowledge and belief.
Date:
Signature:
Title:
User Performing Certification:
Footnotes:
Form CMS 21B Summary
Report Date: Tuesday, June 13, 2023 - 02:42 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Children's Health Insurance Program Budget Report
For the Title XXI Program State
Expenditure Plan
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
State:
Program: N/A
Fiscal Year and Quarter
Total Computable
Federal Share
State Share
(A)
(B)
(C)
Fiscal Year:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
Fiscal Year:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
Form CMS 21B
Report Date: Tuesday, June 13, 2023 - 02:42 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Children's Health Insurance Program Budget Report
21B Narratives
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
State:
Other Narrative Explanations
SPA
Dollar Amount
Miscellaneous
Dollar Amount
Supporting Documents
File Name
Form CMS 21B Narrative
Description
Uploaded By
Uploaded Date
Report Date: Tuesday, June 13, 2023 - 02:42 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Children's Health Insurance Program Budget Report
21B Narratives
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
State:
Supporting Documents and Justification
CMS-21B Submission
Supporting Documents
File Name
Description
Uploaded By
Uploaded Date
Uploaded By
Uploaded Date
No Records
Explanation / Justification
No entries available
CMS-21B Summary
Supporting Documents
File Name
Description
No Records
Explanation / Justification
No entries available
CMS-21B AL-NA
Supporting Documents
Form CMS 21B Narrative
Report Date: Tuesday, June 13, 2023 - 02:42 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Children's Health Insurance Program Budget Report
21B Narratives
OMB No. 0938-1265
Expires 04/30/2024
Submission Date:
Certification Qtr:
State:
File Name
Description
Uploaded By
Uploaded Date
Explanation / Justification
No entries available
Form CMS 21B Narrative
Report Date: Tuesday, June 13, 2023 - 02:42 PM
| File Type | application/pdf |
| File Modified | 2023-12-11 |
| File Created | 2023-06-13 |