The Quarterly Children's Health Insurance Program (CHIP) Statement of Expenditures for Title XXI (Form CMS-21) is the state's accounting statement of actual recorded expenditures and the disposition of Federal funds which the states, in accordance with Sections 2105(e) and 2107(b)(1) of the Act, must submit each quarter under Title XXI of the Act. Expenditures reported on this form primarily include those made to initiate and expand health insurance coverage to uninsured, low-income children through a separate CHIP. Administrative costs associated with expanding child health insurance coverage to uninsured, low-income children through an expansion of a State Medicaid program may also be included on the Form CMS-21 if the state opts to claim Federal Financial Participation at the enhanced Federal Medical Assistance Percentage. Program services costs associated with expanding child health insurance coverage to uninsured, low-income children through an expansion of a State Medicaid program are not reported on the Form CMS-21. These costs are reported on the Form CMS-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program. 

CMS-21 Category of Service Definitions is available for reference when completing form CMS-21. Summary state-by-state total expenditures by program for the Medicaid Program, Medicaid Administration and CHIP programs are available in Net Reported Medicaid & CHIP Expenditures.

Form CMS-21 Details

The Form CMS-21 shows the disposition of Federal CHIP grant funds for the quarter being reported and previous fiscal quarters and years, recoupments made or refunds received, adjustments for overpayments or underpayments, and adjustments for premiums or cost-sharing amounts received.

The amounts reported on Form CMS-21 and its attachments must be actual recorded expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. Form CMS-21 is an accounting statement of actual expenditures for which states are entitled to Federal reimbursement under Title XXI and which reconciles any advance of Title XXI Federal funds made on the basis of estimates provided on the Form CMS-21B. Reconciliations of expenditures to estimates, however, will not occur until after the period of availability for allotments has expired.

The amount claimed on the Form CMS-21 is a summary of actual expenditures derived from source documents such as invoices, cost reports and eligibility records. All summary statements or descriptions of each claim must identify the claim and source documentation. Claims developed through the use of sampling, projections, or other estimating techniques are considered estimates and are not allowable under any circumstances. If a state is unable to develop and document a claim for expenditures on a current basis, the state must withhold the claim until the actual amount, supported by final documentation, has been determined. The state then reports that amount on a future Form CMS-21P as a prior period adjustment.

Submission

The WEB-based Medicaid and CHIP Budget and Expenditure System (MBES/CBES) has allowed the states to electronically submit their Form CMS-21 directly to the CMS Data Center and the Medicaid/CHIP data base. When using the MBES/CBES, states do not have to submit a hard copy of the signed certification statement to CMS. We have modified the MBES/CBES to allow states to complete the signature/certification form through the MBES/CBES and simply transmit this form to us. Signed hard copies must be maintained at the state.