Form CMS-21 Quarterly CHIP Statement of Expenditures for the Title X

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

OMB No. 0938-0731
Expires 8/31/2011

Quarterly Children's Health Insurance Program
Statement of Expenditures for Title XXI
Summary Sheet
State:
Quarter Ended: 12/31/2010
Expenditures Reported for Period

Title XXI Expenditures
Total Computable
(A)

1
2
3
4
5
6

Federal Share
(B)

Expenditures In This Quarter (Form CMS 21 Base)
Adjustments Increasing Claims For Prior Quarters (Form CMS 21P)
Adjustments Decreasing Claims For Prior Quarters (Form CMS 21P)
Adjustments/Decreasing Claims - Perm (Form CMS 21Perm)
Adjustments - Decreasing Claims - Overpayments
Net Expenditures Reported In This Period

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. This report only includes expenditures under the Children's Health Insurance Program (CHIP) under Title XXI of the Act that
are allowable in accordance with applicable implementing federal, state and local statutes, regulations, policies, and the
Children's Health Plan approved by the Secretary and in effect in the Quarter Ended indicated above under Title XXI of the Act.
3. The expenditures included in this report are based on the state's accounting of actual recorded expenditures, and are not
based on estimates.
4. The required amount of state and/or local funds were available and used to match the state's allowable expenditures
included in the report, and such state and/or local funds were in accordance with all applicable federal requirements for the
non-federal share match of expenditures.
5. Federal matching funds are not being claimed on the report to match any expenditures under any Children Health Plan
amendment that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the Quarter
Ended indicated above.
6. The information shown above and on the form CMS-21 Summary Sheet and the Supporting Schedules is correct to the best of my
knowledge and belief.

Date:

Signature:

Title:

User Performing Certification:
Footnotes:

The completed Budget, Expenditure and supporting forms are to be submitted via the on-line MBES/CBES system to the Centers of Medicare & Medicaid
Services, Center for Medicaid and State Operations, Finance, Systems and Quality Group, Division of Financial Management, located at Mailstop S3-13-15,
7500 Security Blvd., Baltimore, Maryland 21244-1850.

Form CMS 21 Summary

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010

Program Code

1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16

10% Limit:
Total
Total
10% Limit: Total Federal
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

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

Form CMS 21 Base

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010

Program Code
17
18
19
20
21
22
23
24
25
31
32
32A
32B
33
34
35
35A
35B
48
49
50

10% Limit:
Total
Total
10% Limit: Total Federal
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

Abortions No.
Screening Services
Home Health
Reserved
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
Other Services
Outreach
Increased Outreach and Enrollment of
Indians
Increase Outreach and Enrollment of
children through premium subsidies
Administration
PERM Administration
Citizenship Verification TechnologyCHIPRA
CVT Development
CVT Operation
Balance
Less: Collections
Total

Form CMS 21 Base

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010

Program Code

1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15
16

10% Limit:
Total
Total
10% Limit: Total Federal
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

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

Form CMS 21

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010

Program Code
17
18
19
20
21
22
23
24
25
31
32
32A
32B
33
34
35
35A
35B
48
49
50

10% Limit:
Total
Total
10% Limit: Total Federal
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

Abortions No.
Screening Services
Home Health
Reserved
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
Other Services
Outreach
Increased Outreach and Enrollment of
Indians
Increase Outreach and Enrollment of
children through premium subsidies
Administration
PERM Administration
Citizenship Verification TechnologyCHIPRA
CVT Development
CVT Operation
Balance
Less: Collections
Total

Form CMS 21

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments

State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line:

Program Code:

1A
1B
1C
1D
2
3
4
5
6
7
8
8A
9
10
11
12
13
14
15

10% Limit:
Deferral
Total
10% Limit: Total Federal Disallowance
Total
Computable Federal Share Computable Federal Share
Share
C.I.N. No.
(A)
(B)
(C)
(D)
(E)
(F)

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

Form CMS 21.P

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments

State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line:

Program Code:
16
17
18
19
20
21
22
23
24
25
31
32
32A
32B
33
34
35
35A
35B
48
49
50

10% Limit:
Deferral
Total
10% Limit: Total Federal Disallowance
Total
Computable Federal Share Computable Federal Share
Share
C.I.N. No.
(A)
(B)
(C)
(D)
(E)
(F)

Family Planning
Abortions No.
Screening Services
Home Health
Reserved
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
Other Services
Outreach
Increased Outreach and Enrollment of
Indians
Increase Outreach and Enrollment of
children through premium subsidies
Administration
PERM Administration
Citizenship Verification TechnologyCHIPRA
CVT Development
CVT Operation
Balance
Less: Collections
Total

Form CMS 21.P

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Insurance Program Expenditures
For the Title XXI Program
Calclulation of 10% Limit
State:
Quarter Ended: 12/31/2010
Total Computable
(A)
1A
1B
2A
2B
3
4
5
6
7
8A
8B
9
9A
9B
9C
9D
9E
9F
10

Federal Share
(B)

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 Enhanced
FMAP)
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)
Expenditures Currently Claimed Under Section 2105(a)(2)
Total Of Lines 8A And 8B
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 of lines 8A, 8B and 9E.
Amount Under/(Over) Limit (Line 7 Minus 9)

Form CMS 21.L

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Insurance Program Expenditures
For the Title XXI Program

State:
Quarter Ended: 12/31/2010

1

Retained
Application of 10% Outreach Allowance For FY Allotment and
1998 Retained Allotment States Used in the
Expenditure
Calculation of 10% Fiscal Year Limit
Amounts
(A)
Beginning Balance

6

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

7
8

Previously Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Administration
Balance From Previous Quarter

2
3
4

5

14

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

15
16

Currently Claimed Section 2105(a)(1)(D) CHIP
Expenditures in Fiscal Year - Administration
Net

9
10
11

12
13

Form CMS 21L Outreach Allowance

Remaining
Outreach
Allowance or
Expenditure
Amount
(B)

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

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

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Allocation of the Title XIX and Title XXI Expenditures
To CHIP Fiscal Year Allotment
State:
Quarter Ended: 12/31/2010

Qualifying State
(A)
1
2
3
4
5
6
7
8
9
10
11
12
13

FYY 2006 (10/01/2005 - 09/30/2006)
FFY 2003 Redistributed Allotment
FFY 2006 Shortfall
Unused FFY 2004 Allotment
Unused FFY 2005 Allotment
FFY 2006 Allotment
Excess Previously Claimed in Prior Years
First Quarter 2006
Second Quarter 2006
Third Quarter 2006
Fourth Quarter 2006
Excess 10% Limit
Unused Allotment
Excess Expenditures

14

FFY 2004 Allotment added to Redistribution Pool

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

FYY 2007 (10/01/2006 - 09/30/2007)
FFY 2004 Redistributed Allotment
FFY 2005 Redistributed Allotment
FFY 2007 Shortfall
Negative Adjustment FFY 2005 Allotment
Unused FFY 2005 Allotment
Unused FFY 2006 Allotment
FFY 2007 Allotment
Excess Previously Claimed in Prior Years
First Quarter 2007
Second Quarter 2007
Third Quarter 2007
Fourth Quarter 2007
Excess 10% Limit
Unused Allotment
Excess Expenditures

16

FFY 2005 Allotment added to Redistribution Pool

1
2
3
4
5
6
7
8
9
10
11
12
13

FYY 2008 (10/01/2007 - 09/30/2008)
FFY 2005 Redistributed Allotment
Unused FFY 2006 Allotment
Unused FFY 2007 Allotment
FFY 2008 Allotment
FFY 2008 Shortfall
Excess Previously Claimed in Prior Years
First Quarter 2008
Second Quarter 2008
Third Quarter 2008
Fourth Quarter 2008
Excess 10% Limit
Unused Allotment
Excess Expenditures

Form CMS 21C

Federal Share Expenditures Only
Title XIX
Title XXI
1905(u)(2)(3)
PE
2105(a)(1)(C)
2105(a)(1)(D)
(B)
(C)
(D)
(E)

Total
(F)

Balance
(G)

Unused
(H)

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Allocation of the Title XIX and Title XXI Expenditures
To CHIP Fiscal Year Allotment
State:
Quarter Ended: 12/31/2010

Qualifying State
(A)
14

FFY 2006 Allotment added to Redistribution Pool

1
2
3
4
5
6
7
8
9
10
11
12
13
14

FYY 2009 (10/01/2008 - 09/30/2009)
FFY 2006 Redistributed Allotment
Unused FFY 2007 Allotment
Unused FFY 2008 Allotment
FFY 2009 Allotment
FFY 2009 Shortfall
FFY 2009 CHIPRA (Issued 4/1/2009)
Excess Previously Claimed in Prior Years
First Quarter 2009
Second Quarter 2009
Third Quarter 2009
Fourth Quarter 2009
Excess 10% Limit
Unused Allotment
Excess Expenditures

15

FFY 2007 Allotment added to Redistribution Pool

1
2
3
4
5
6
7
8
9
10
11
12
13

FYY 2010 (10/01/2009 - 09/30/2010)
FFY 2007 Redistributed Allotment
Unused FFY 2008 Allotment
Unused FFY 2009 Allotment
Unused FFY CHIPRA (2009)
FFY 2010 Allotment
Excess Previously Claimed in Prior Years
First Quarter 2010
Second Quarter 2010
Third Quarter 2010
Fourth Quarter 2010
Excess 10% Limit
Unused Allotment
Excess Expenditures

14

FFY 2008 Allotment added to Redistribution Pool

Form CMS 21C

Federal Share Expenditures Only
Title XIX
Title XXI
1905(u)(2)(3)
PE
2105(a)(1)(C)
2105(a)(1)(D)
(B)
(C)
(D)
(E)

Total
(F)

Balance
(G)

Unused
(H)

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:

1D
2
3
4
5
6

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

7
8
8A
9
10
11

Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Practitioners' Services

1A

1B

1C

Form CMS 21 Waiver

10% Limit:
Total
10% Limit: Total Federal
Total
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:

10% Limit:
Total
10% Limit: Total Federal
Total
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

12
13
14

Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical
15 Equipment
16 Family Planning
17 Abortions No.
18 Screening Services
19 Home Health
20 Reserved
21 Home And Community-Based Services
22 Hospice
23 Medical Transportation
24 Case Management
25 Translation and Interpretation
31 Other Services
32 Outreach
Increased Outreach and Enrollment of
32A Indians
Increase outreach and enrollment of
32B children through premium subsidies
33 Administration
34 PERM Administration

Form CMS 21 Waiver

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Children's Health Expenditures by Type of Service
For the Title XXI Program
Expenditures in this Quarter
State:
Quarter Ended: 12/31/2010
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:

35
35A
35B
48
49
50

10% Limit:
Total
10% Limit: Total Federal
Total
Computable Federal Share Computable Federal Share
Share
(A)
(B)
(C)
(D)
(E)

Citizenship Verification TechnologyCHIPRA
CVT Development
CVT Operation
Balance
Less: Collections
Total

Form CMS 21 Waiver

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments

State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line:
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:

1D
2
3
4
5
6

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

7
8
8A
9
10
11

Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate
Dental Services
Vision Services
Other Pracitioners' Services

1A

1B

1C

Form CMS 21.P Waiver

Total
Computable
(A)

Federal Share
(B)

10% Limit:
Total
Computable
(C)

Deferral
10% Limit:
Total Federal Disallowance
Federal Share
Share
C.I.N. No.
(D)
(E)
(F)

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments

State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line:
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:
12
13
14

Total
Computable
(A)

Federal Share
(B)

10% Limit:
Total
Computable
(C)

Deferral
10% Limit:
Total Federal Disallowance
Federal Share
Share
C.I.N. No.
(D)
(E)
(F)

Clinic Services
Therapy Services
Laboratory And Radiological Services

15
16
17
18
19
20
21
22
23
24
25
31
32

Durable And Disposable Medical Equipment
Family Planning
Abortions No.
Screening Services
Home Health
Reserved
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Translation and Interpretation
Other Services
Outreach
Increased Outreach and Enrollment of
32A Indians
Increase Outreach and Enrollment of
32B children through premium subsidies
33 Administration
34 PERM Administration

Form CMS 21.P Waiver

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures by Type of Service
For the Title XXI Program
Prior Period Adjustments

State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line:
Covers:
Program Code
Waiver Type:
Waiver Name:
Waiver Number:

35
35A
35B
48
49
50

Total
Computable
(A)

Federal Share
(B)

10% Limit:
Total
Computable
(C)

Deferral
10% Limit:
Total Federal Disallowance
Federal Share
Share
C.I.N. No.
(D)
(E)
(F)

Citizenship Verification TechnologyCHIPRA
CVT Development
CVT Operation
Balance
Less: Collections
Total

Form CMS 21.P Waiver

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Provider Related Donations And
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Actual Receipts By Plan Name
Code:
1. Donations - General
2. Donations - Outstanding Eligibility Workers - Specific
3. Taxes
4. Fees
5. Assessments
Code
(A)

Form CMS 21.11A

Plan Name
(B)

Receipts
(C )

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011

Provider Related Donations And
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Summary Total of Receipts From Form CMS21.11 A
State:
Plan Name
(A)
1
2
3
4
5
6
7

Receipts
(B)

Donations
Donations - General
Donations- Outstationed Eligibility Workers - Specific
Taxes
Taxes
Fees
Fees
Assessments
Assessments
Totals
Total Donations (Lines 1 + 2)
Total Taxes, Fees, and Assessments (Lines 3 + 4 + 5)

Form CMS 21.11

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustment PERM

State:
Quarter Ended: 12/31/2010

PERM Activity

Total
Computable

(A)

1
2
3

4
5

FY 2008
(B)

Federal Share
PERM-Identified Overpayments
FY 2009
FY 2010
(C )
(D)

Total Federal
Share
FY 2011
(E)

(J)

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

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Insurance Program Expenditures
For The Title XXI Program

State:
Quarter Ended: 12/31/2010
Application of Medicaid Qualifying State Allowance For FY 2007
Thru 2009
1
2
3
4
5
6
7

Beginning Balance
Allotment Remaining
Net Remaining Balance (Lesser of Line 1 or Line 2)
Currently Claimed CHIP Expenditures in Fiscal Year
Ending Balance (Line 3 Minus Line 4)
Other CHIP Expenditures claimed this quarter (From 21C, Columns
B, C, D and E)
Allotment remaining at end of quarter (From 21C, Column H)

8

20% Allowance balance at end of quarter (Lesser of Lines 5 or 7)

Form CMS 21T Tracking

20% Medicaid
FY 2008
(A)

Medicaid FY
2009
(B)

Non
Applicable
(C)

Not Applicable
(D)

Report Date: Friday, November 12, 2010 - 12:00 AM

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

OMB No. 0938-0731
Expires 8/31/2011
Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustments

State:
Quarter Ended: 12/31/2010
Overpayment Activity

Total
Computable
(A)

1
2
3

4
5

FY 2008
(B)

Federal Share
FY 2009
FY 2010
(C )
(D)

Total Federal
Share
FY 2011
(E)

(J)

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

Report Date: Friday, November 12, 2010 - 12:00 AM