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Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI
ICR 202611-0938-007 · OMB 0938-1265 · Object 174991400.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Quarterly Children’s Health Insurance Program Statement of Expenditures for Title XXI |
| Author | Apache POI |
| Last Modified By | Calc |
| File Modified | 2026-11-09 |
| File Created | 2026-11-11 |
| Conversion State | complete |
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Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 Summary - Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI Summary Sheet State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Line Item 1 2 3 4 4A 5 6 6A 7 Line Item Description Expenditures Adjustments - Increasing Claims Adjustments - Decreasing Claims Adjustments Decreasing Claims - Collections Adjustments Decreasing Claims - MEQC Collections Adjustments - Decreasing Claims - Perm Adjustments - Decreasing Claims - Overpayments Adjustments Decreasing Claims - MEQC Overpayments Net Expenditures Form CMS 21 Summary Total Computable Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Program Federal Share Form CMS 21 Summary Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21L - Children's Health Insurance Program Expenditures For the Title XXI Program Calculation of 10% Limit State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Line Item Line Item Description 1A 1B 2A 2B 3 4 5 6 7 8A 8A1 8B 8B1 9 9A 9B 9C 9D 9E 9F 10 Previously Claimed Expenditures - Section 2105(a)(1)(C) Previously Claimed Expenditures - Section 2105(a)(1)(A) Expenditures Claimed In The Current Quarter - Section 2105(a)(1)(C) Expenditures Claimed In The Current Quarter - Sections 2105(a)(1)(A) Total Of Column (a) Lines 1A & B And 2A & B 10% Limit (Divide Line 3 Column (a) By 9) Total Computable - Allotment (Allotment Divided By The CHIP Rate) 10% Of The Allotment - Total Computable (10% Times Line 5) 10% Limit (Lesser Of Lines 4 Column (a) Or 6 Column (a)) Expenditures Previously Claimed Under Section 2105(a)(2) HSI Previously Claimed under Section 2105(a)(2) Expenditures Currently Claimed Under Section 2105(a)(2) 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 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 m Expenditures 027 Total Computable (A) Form CMS 21.L Federal Share (B) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21C - Allocation of Ti To CHIP Fisca St Submission Quarter Quarter Ende Line Item Line Item Description 1 2 3 4 5 6 7 8 9 10 11 12 FFY XXXX_MINUS_TWO and prior Redistributed Allotment Unused FFY XXXX_MINUS_ONE Allotment FFY XXXX Allotment Excess Previously Claimed in Prior Years First Quarter XXXX Second Quarter XXXX Third Quarter XXXX Fourth Quarter XXXX Excess 10% Limit Unused Allotment Excess Expenditures FFY XXXX_MINUS_ONE Allotment Added To Redistribution Pool Form CMS 21.C Qualifying State (A) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 m CMS 21C - Allocation of Title XIX and Title XXI Expenditures To CHIP Fiscal Year Amount State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Title XIX - Sec. 1905 (B) Form CMS 21.C Title XIX - PE (C) Title XXI - Sec. 2105(a)(1) (D) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Title XXI - Sec. 2105(a)(2) (E) Form CMS 21.C Total (F) Balance (G) OMB No. 0938-1265 Expires 4/30/2027 Unused (H) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 Base - Children's Health Ex For the Title XXI P Expenditures in thi State: Submission Quarter/Fisca Quarter Ended: 12 Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21 Base Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 35B 50 OMB No. 0938-1265 Expires 4/30/2027 CVT Operation Total Form CMS 21 Base Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 rm CMS 21 Base - Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Total Computable (A) Form CMS 21 Base Federal Share (B) 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Base OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 10% Limit: Federal Share (D) Form CMS 21 Base OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (E) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Base OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 - Children's Health Expe For the Title XXI P Expenditures by State: Submission Quarter/Fisca Quarter Ended: 12 Program: Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 CVT Development CVT Operation Total Form CMS 21 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 - Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures by Quarter State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Program: Total Computable (A) Form CMS 21 Federal Share (B) 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 10% Limit: Federal Share (D) Form CMS 21 OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (E) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 114 - Children's Health Ex For the Title XXI P Expenditures by State: Submission Quarter/Fisca Quarter Ended: 12 Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 35B 50 OMB No. 0938-1265 Expires 4/30/2027 CVT Operation Total Form CMS 21 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 rm CMS 21 114 - Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures by Quarter State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Total Computable (A) Form CMS 21 114 Federal Share (B) 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 10% Limit: Federal Share (D) Form CMS 21 114 OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (E) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Line Item Overpayment Activity 1 2 3 4 5 Overpayments Not Collected Decreasing Adjustments Sub-Total Previously Reported Overpayments Total Form CMS 21.O OMB No. 0938-1265 Expires 4/30/2027 Total Computable (A) 2024 And Prior: All Others (B1) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 2024 And Prior: MC MLR (B2) Form CMS 21.O 2024 And Prior: MC Financial Penalties (B3) OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21O - Children's Health Expenditures For the Title XXI Program Overpayment Adjustments State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 2025: 2025: 2025: All Others MC MLR MC Financial Penalties (C1) (C2) (C3) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 s 2026: All Others (D1) 2026: MC MLR (D2) Form CMS 21.O 2026: MC Financial Penalties (D3) 2027: All Others (E1) 2027: MC MLR (E2) 2027: MC Financial Penalties (E3) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (F) Form CMS 21.O Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21OMEQC - Children's Health Expenditures For the Title XXI Program Overpayment Adjustments - MEQC State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Line Item Overpayment Activity 1 2 3 4 5 Overpayments Not Collected Decreasing Adjustments Sub-Total Previously Reported Overpayments Total Form CMS 21.OMEQC Total Computable (A) 2022 And Prior (B) 2023 (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 ditures 7 2024 2025 Total Federal Share (D) (E) (F) Form CMS 21.OMEQC Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21 PERM - Children's Health Expenditures For the Title XXI Program Overpayment Adjustment PERM State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Line Item Overpayment Activity 1 2 3 4 5 Overpayments Not Collected Decreasing Adjustments Sub-Total Previously Reported Overpayments Total Form CMS 21.Perm Total Computable (A) 2022 And Prior (B) 2023 (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 itures 7 2024 2025 Total Federal Share (D) (E) (F) Form CMS 21.Perm Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21WAIVER - Children's Health For the Title XXI P Expenditures in thi State: Submission Quarter/Fisca Quarter Ended: 12 Waiver Typ Waiver Numb Waiver Nam Program: Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21 Waiver Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 33 34 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 Administration PERM Administration Citizenship Verification Technology-CHIPRA CVT Development CVT Operation Total Form CMS 21 Waiver Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 m CMS 21WAIVER - Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Waiver Type: Waiver Number: Waiver Name: Program: Total Computable (A) Federal Share (B) Form CMS 21 Waiver 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Waiver OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 10% Limit: Federal Share (D) Form CMS 21 Waiver OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (E) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Waiver OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21WAIVER 114 - Children's Healt For the Title XXI P Expenditures in thi State: Submission Quarter/Fisca Quarter Ended: 12 Waiver Typ Waiver Numb Waiver Nam Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21 Waiver 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 34 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 PERM Administration Citizenship Verification Technology-CHIPRA CVT Development CVT Operation Total Form CMS 21 Waiver 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 CMS 21WAIVER 114 - Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Waiver Type: Waiver Number: Waiver Name: Total Computable (A) Federal Share (B) Form CMS 21 Waiver 114 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Waiver 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 10% Limit: Federal Share (D) Form CMS 21 Waiver 114 OMB No. 0938-1265 Expires 4/30/2027 Total Federal Share (E) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21 Waiver 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21P - C Subm Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21.P Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 34 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 PERM Administration Citizenship Verification Technology-CHIPRA CVT Development CVT Operation Total Form CMS 21.P Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21P - Children's Health Expenditures by Type of Service For the Title XXI Program Prior Period Adjustments State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Prior Qtr/FYR: / Line: Program: Total Computable (A) Form CMS 21.P Federal Share (B) 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Service 10% Limit: Federal Share (D) Form CMS 21.P Total Federal Share (E) Deferral Disallowance C.I.N. No. (F) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21P 114 Subm Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community 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 Form CMS 21.P 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 Citizenship Verification Technology-CHIPRA CVT Development CVT Operation Total Form CMS 21.P 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21P 114 - Children's Health Expenditures by Type of Service For the Title XXI Program Prior Period Adjustments State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Prior Qtr/FYR: / Line: Total Computable (A) Form CMS 21.P 114 Federal Share (B) 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 of Service 10% Limit: Federal Share (D) Form CMS 21.P 114 Total Federal Share (E) Deferral Disallowance C.I.N. No. (F) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21PWAIVE Subm Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community Hospice Medical Transportation Case Management Translation and Interpretation ARP Section 9821 COVID Vaccine/Vaccine Administration Other Services Outreach Form CMS 21.P Waiver Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 32A 32B 33 34 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 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 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21PWAIVER - Children's Health Expenditures by Type of Service For the Title XXI Program Prior Period Adjustments State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Prior Qtr/FYR: / Line: Waiver Type: Waiver Number: Waiver Name: Program: Total Computable (A) Federal Share (B) Form CMS 21.P Waiver 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P Waiver OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 e of Service 10% Limit: Federal Share (D) Form CMS 21.P Waiver Total Federal Share (E) Deferral Disallowance C.I.N. No. (F) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P Waiver OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21PWAIVER 1 Subm Line Item Line Item Description 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 Premiums - Up To 150%: Gross Premiums Paid Premiums - Up To 150%: Cost Sharing Offset Premiums - Over 150%: Gross Premiums Paid Premiums - Over 150%: Cost Sharing Offset Inpatient Hospital Inpatient Mental Health Nursing Care Services Physician/Surgical Outpatient Hospital Outpatient Mental Health Prescribed Drugs Drug Rebate Dental Services Vision Services Other Practitioners Clinic Services Therapy Services Laboratory/Radiological Medical Equipment Family Planning Abortions Screening Services Home Health Health Services Initiatives Home and Community Hospice Medical Transportation Case Management Translation and Interpretation ARP Section 9821 COVID Vaccine/Vaccine Administration Other Services Outreach Increased Outreach and Enrollment of Indians Form CMS 21.P Waiver 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services 32B 33 34 35 35A 35B 50 OMB No. 0938-1265 Expires 4/30/2027 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 114 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Form CMS 21PWAIVER 114 - Children's Health Expenditures by Type of Service For the Title XXI Program Prior Period Adjustments State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Prior Qtr/FYR: / Line: Waiver Type: Waiver Number: Waiver Name: Total Computable (A) Federal Share (B) Form CMS 21.P Waiver 114 10% Limit: Total Computable (C) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P Waiver 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 pe of Service 10% Limit: Federal Share (D) Form CMS 21.P Waiver 114 Total Federal Share (E) Deferral Disallowance C.I.N. No. (F) Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS 21.P Waiver 114 OMB No. 0938-1265 Expires 4/30/2027 Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 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: 12/31/2026 Total Receipts T1. Donations 1 Donations - General 2 Donations- Outstationed Eligibility Workers - Specific T2. Taxes 3 Taxes T3. Fees 4 Fees T4. Assessments 5 Assessments T5. Totals 6 Total Donations (Lines 1+2) 7 Total Taxes, Fees, and Assessments (Lines 3+4+5) Form CMS 21.11 Provider Created On: 11/09/2026 11:36 AM ET Department of Health and Human Services Centers for Medicare & Medicaid Services OMB No. 0938-1265 Expires 4/30/2027 Medicaid Program Expenditure Report Other Narrative Explanations State: Submission Quarter/Fiscal Year: Q1/2027 Quarter Ended: 12/31/2026 Narrative Form CMS 21.Narrative Created On: 11/09/2026 11:36 AM ET