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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
State:
CMS 64 Summary Sheet
Quarter Ended:
Certification
Medical Assistance Payments
State and Local Administration
Total Computable
Federal Share
Total Computable
Federal Share
(A)
(B)
(C)
(D)
Net Expenditures Reported In This Period (Sum of Items 6,
7 and 8 Less 9 and 10)
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 Medicaid program under title XIX of the Social Security Act (the Act), and as applicable, under the State
Children’s Health Insurance Program (SCHIP) under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local
statutes, regulations, policies, and the state plan approved by the Secretary and in effect during the Quarter Ended indicated above under Title XIX of the Act for
the Medicaid program, and as applicable, under Title XXI of the Act for the SCHIP.
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 this 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 this report to match any expenditure under any Medicaid and/or SCHIP state 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-64 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 for 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 64 Certification
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended:
Medical Assistance Payments State and Local Administration
Total
Federal Share
Total
Federal Share
(A)
(B)
(C)
(D)
Section A. Quarterly Status of Funding
1
Awards Received During The Quarter For The Quarter Being
Reported And Prior Quarters
2
Awards Received During The Quarter For Subsequent
Quarters
3A
Interest: Received On Medicaid Recoveries
3B
Interest: Assessed On Disallowances
4
Medicare Overpayment Collection Under Sec. 1914 and 42
CFR 447.30
5
Other
Section B. Expenditures Reported for Period
6
Expenditures In This Quarter
7
Adjustments Increasing Claims For Prior Quarters
8
Other Expenditures
9A
Collections: Third Party Liability
9B
Collections: Probate
9C
Collections: Identified Through Fraud And Abuse Effort
9D
Collections: Other
9E
Misc.
10A
Adjustments Decreasing Claims For Prior Quarters: Federal
Audit
10B
Adjustments Decreasing Claims For Prior Quarters: Other
10C Adjustments Decreasing Claims For Prior Quarters:
Overpayment Adjustments (Attach 64.9O)
11
Net Expenditures Reported In This Period (Sum of Items 6, 7
and 8 Less 9 and 10)
Form CMS 64 Summary
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
IHS Facility Fam. Plan.
Medical Assistance Payments
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH
Adjustment Payments
2A
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3
Nursing Facility Services
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
5
Physicians' Services
6
Outpatient Hospital Services
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar
Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions No.
15
EPSDT Screening Services
16
Rural Health Clinic Screening
17A
Medicare Health Insurance Payments Part A Premiums
17B
Medicare Health Insurance Payments Part B Premiums
Total
Comp.
(A)
FMAP
(B)
Services
100%
(C)
Services
90%
(D)
Optional
Breast or
Cerv. Cancer
Services
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
(G)
17C1 120% - 134% Of Poverty
17C2 135% - 175% Of Poverty
17D
Coinsurance And Deductibles
Form CMS 64.9 Base
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
IHS Facility Fam. Plan.
Medical Assistance Payments
18A
Total
Comp.
(A)
FMAP
(B)
Services
100%
(C)
Services
90%
(D)
Optional
Breast or
Cerv. Cancer
Services
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
(G)
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments:
Other
19
Home And Community-Based Services
20
Home And Community-Based Care For
Functionally Disabled Elderly
22
Programs Of All-Inclusive Care Elderly
23
Personal Care Services
24
Targeted Case Management Services
25
Primary Care Case Management Services
26
Hospice Benefits
27
Emergency Services Undocumented
Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
Form CMS 64.9 Base
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Quarter Ended:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Inpatient Hospital Services - Regular Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
Mental Health Facility Services - Regular Payments
2A
2B
3
4A
5
6
Outpatient Hospital Services
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions No.
15
EPSDT Screening Services
16
Rural Health Clinic Screening
17A
17C1
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
120% - 134% Of Poverty
17C2
135% - 175% Of Poverty
17D
Coinsurance And Deductibles
18A
18B1
Medicaid Health Insurance Payments: Managed Care
Organizations (MCO)
Prepaid Ambulatory Health Plan
18B2
Prepaid Inpatient Health Plan
18C
18E
Medicaid Health Insurance Payments: Group Health
Plan Payments
Medicaid Health Insurance Payments: Coinsurance
And Deductibles
Medicaid Health Insurance Payments: Other
19
Home And Community-Based Services
20
22
Home And Community-Based Care For Functionally
Disabled Elderly
Programs Of All-Inclusive Care Elderly
23
Personal Care Services
24
Targeted Case Management Services
25
Primary Care Case Management Services
26
Hospice Benefits
27
Emergency Services Undocumented Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
17B
18D
FMAP
(B)
0.00%
Federal
Share
(F)
Total
Federal
Share
(G)
Mental Health Facility Services - DSH Adjustment
Payments
Nursing Facility Services
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
Physicians' Services
4B
Total
Comp
(A)
Federal Share
IHS Facility Family Plan. Opt. Brst.
& Cerv.
Services Services
Cancer
100%
90%
Services
(C)
(D)
(E)
Form CMS 64.9 Waiver
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Medical Assistance Payments
1A
Inpatient Hospital Services: Regular
Payments
1B
Inpatient Hospital Services: DSH
Adjustment Payments
2A
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
3
Nursing Facility Services
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
5
Physicians' Services
6
Outpatient Hospital Services
7
Prescribed Drugs
Total
Comp.
FMAP
(A)
(B)
I.H.S Fac. Fam. Pln. Opt. Brst or
Cerv.
Services Services
Cancer
Services
100%
90%
(C)
(D)
(E)
0.00%
Federal
Share
(F)
7A1 Drug Rebate Offset - National
Agreement
7A2 Drug Rebate Offset - State Sidebar
Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions
15
EPSDT Screening Services
16
Rural Health Clinic Services
17A Medicare Health Insurance Payments:
Part A Premiums
17B Medicare Health Insurance Payments:
Part B Premiums
Form CMS 64.9P
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Medical Assistance Payments
Total
Comp.
FMAP
(A)
(B)
I.H.S Fac. Fam. Pln. Opt. Brst or
Cerv.
Services Services
Cancer
Services
100%
90%
(C)
(D)
(E)
0.00%
Federal
Share
(F)
17C1 Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of
Poverty
17C2 Medicare Health Insurance Payments:
Qualifying Individuals/135% - 175% of
Poverty
17D Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A Medicaid Health Insurance Payments:
Managed Care Organizations
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
18C Medicaid Health Insurance Payments:
Group Health Plan Payments
18D Medicaid Health Insurance Payments:
Coinsurance and Deductibles
18E Medicaid Health Insurance Program:
Other
19
Home And Community-Based Services
20
Home And Community-Based Care For
Functionally Disabled Elderly
22
Programs Of All-Inclusive Care Elderly
23
Personal Care Services
24
Targeted Case Management Services
25
Primary Care Case Management
Services
26
Hospice Benefits
27
Emergency Services Undocumented
Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
Form CMS 64.9P
Thursday, February 14, 2008 - 11:03 AM
OMB No. 0938-0067
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medical Assistance
Waiver Type:
Waiver Name:
Waiver Number:
FMAP
Total
Comp.
(A)
1A
Inpatient Hospital Services: Regular
Payments
1B
Inpatient Hospital Services: DSH
Adjustment Payments
2A
Mental Health Facility Services:
Regular Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
3
Nursing Facility Services
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
5
Physicians' Services
6
Outpatient Hospital Services
7
Prescribed Drugs
7A1
Drug Rebate - National Agreement
7A2
Drug Rebate - State Sidebar
Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological
Services
12
Home Health
13
Sterilizations
14
Abortions
15
EPSDT Screening Services
16
Rural Health Clinic Services
17A
Medicare Health Insurance
Payments: Part A Premiums
Form CMS 64.9P Waiver
(B)
I.H.S Fac. Fam. Plan. Opt. Brst &
Cerv.
Services Services
Cancer
100%
90%
Services
(C)
(D)
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Thursday, February 14, 2008 - 11:03 AM
OMB No. 0938-0067
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medical Assistance
Waiver Type:
Waiver Name:
Waiver Number:
FMAP
Total
Comp.
(A)
17B
(B)
I.H.S Fac. Fam. Plan. Opt. Brst &
Cerv.
Services Services
Cancer
100%
90%
Services
(C)
(D)
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Medicare Health Insurance
Payments: Part B Premiums
17C1 Medicare Health Insurance
Payments: Qualifying
Individuals/120% - 134% of Poverty
17C2 Medicare Health Insurance
Payments: Qualifying
Individuals/135% - 175% of Poverty
17D Medicare Health Insurance
Payments: Coinsurance and
Deductibles
18A Medicaid Health Insurance
Payments: Managed Care
Organizations
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
18C
18D
18E
Medicaid Health Insurance
Payments: Group Health Plan
Payments
Medicaid Health Insurance
Payments: Coinsurance and
Deductibles
Medicaid Health Insurance Program:
Other
19
Home And Community-Based
Services
20
Home And Community-Based Care
For Functionally Disabled Elderly
22
Programs Of All-Inclusive Care
Elderly
23
Personal Care Services
24
Targeted Case Management
Services
25
Primary Care Case Management
Services
26
Hospice Benefits
27
Emergency Services Undocumented
Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
Form CMS 64.9P Waiver
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medicaid Overpayment Adjustment
State:
Quarter Ended:
Total
Overpayment Activity
Computable
(A)
1
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The
60-Day Time Limit
2
Decreasing Adjustments To Amounts
Previously Reported On Line 1
3
Subtotal
4
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt
Or Out Of Business
5
Total Overpayment Adjustments This Quarter
Form CMS 64.9O
Federal Share
FY
FY
(B)
FY
(C)
Total Fed
FY
(D)
Share
(E)
(F)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Third Party Liability Collections
And Cost Avoidance
State:
Total Computable
(A)
Quarter Ended:
Federal Share
(B)
A. Third Party Liability Collections
A1A Amount Of Third Liabilty Collections Made In This Quarter By Source:
Medicare Title XVIII
A1B1 Other Collections: Health Insurance
A1B2 Other Collections: Casualty Insurance
A1C Total Collections Under Cooperative Agreements Section 1903(p) And
Assignment of Right Section 1912
A1C1 Total Collections: Less Excess Paid To Individuals
A1C2 Net Collections To Reimburse State Title XIX Medical Payments
A1C3 Less 15% Incentive Actually Paid Under Section 1903(p)(1)
A1C4 Net Federal Share Of Collections Reportable
A2
Total Third Party Liabilty Collections
B. Cost Avoidance
B1
Medicare Title XVIII
B2
Health Insurance
B3
Other Cost Avoidance
Form CMS 64.9A
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug
Claims System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10 Base
FFP
Rate
Quarter Ended:
Federal Share
Federal
Federal
0.00%
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Waiver Type:
Waiver Name:
Waiver Number:
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug Claims
System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private Sector
Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing Offset
8
Immigration Status Verification System Costs (100% FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10 Waiver
Quarter Ended:
Total
Computable
(A)
FFP
Rate
Federal Share
Federal
0.00%
Share
(B)
Federal
Share
(C)
Total
Federal
Share
(D)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Total
FFP
Computable Rate
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs Of
In-House Activities
2B
Design Development Or Installation Of MMIS: Costs Of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug Claims
System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private Sector
Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing Offset
8
Immigration Status Verification System Costs (100% FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10P
Federal Share
Federal
Federal
0.00%
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Deferral Or
C.I.N.
Number
(E)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs Of
In-House Activities
2B
Design Development Or Installation Of MMIS: Costs Of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug
Claims System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private Sector
Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10P Waiver
Total
FFP
Computable Rate
(A)
Federal Share
Federal
Federal
0.00%
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Deferral Or
C.I.N.
Number
(E)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Provider-Related Donations And
Health Care Related Taxes, Fees, And Assessments
Received Under Public Law 102-234
Summary Total Of Receipts From Form CMS 64.11A
State:
Quarter Ended:
Category
Total Receipts
(A)
(B)
Section Heading
Form CMS 64.11
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended:
Inpatient Hospital
Total
Federal
Computable
Share
(A)
(B)
1
FFY Allotment
2
Amount Previously Reported
2A
Amount Previously Reported - CHIP Related - PE
3
Line 6
3A
Line 6 - CHIP Related - PE
4
Line 7
4A
Line 7 - CHIP Related - PE
5
Line 8
5A
Line 8 - CHIP Related - PE
6
Line 10
6A
Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A
Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A
Total - CHIP Related - PE
9
Unused FFY Allotment
Form CMS 64.9D
Mental Health Fac. Serv.
Total
Computable
(C)
Federal
Share
(D)
Total
Total
Computable
(E)
Federal
Share
(F)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Medicaid Drug Rebate Schedule
State:
Quarter Ended:
Total Computable
Qtr. Ending
Qtr. Ending
Qtr. Ending
Qtr. Ending
Qtr. Ending
Total
Drug Rebate
and Prior
(A)
1
Balance Of The Beginning Of The Quarter
2
Adjustments To Previously Reported Rebates
From Drug Labelers Included In Line 1
3
Rebates Invoiced In This Quarter
4
Subtotal
5
Rebates Reported On This Expenditure Report
6
Balance As Of The End Of The Quarter
(B)
(C)
(D)
(E)
(F)
FOOTNOTE:
Form CMS 64.9R
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Federal Share
Type of Eligible:
1A
Premiums: Up To 150% of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% of Poverty Level: Cost Sharing Offsets
1C
Premiums Over 150% of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% of Poverty Level: Cost Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment Payments
4
Nursing Care Services
5
Physican And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21
Total
Comp.
(A)
FMAP
0.00%
(B)
IHS Facility
Fam. Plan.
Services
100%
(C)
Services
90%
(D)
Total
Federal
Share
(E)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Type of Eligible:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing Offset
1C
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing Offset
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
4
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21P
Total
Computable
(A)
FMAP
0.00%
(B)
I.H.S Facility
Fam. Plan.
Services
100%
(C)
Services
90%
(D)
Total
Federal
Share
(E)
Deferral
Or
C.I.N.
Number
(F)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums: Up To 150% of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% of Poverty Level: Cost Sharing Offsets
1C
Premiums Over 150% of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% of Poverty Level: Cost Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment Payments
4
Nursing Care Services
5
Physican And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21 Waiv
Quarter Ended:
Federal Share
Total
Computable
(A)
FMAP
(B)
I.H.S Facility
Fam. Plan.
Services
100%
(C)
Services
90%
(D)
Total
Federal
Share
(E)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended:
Fiscal Year:
Line #
Type Of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing Offset
1C
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing Offset
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
4
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21P Waiver
Federal Share
Total
Computable
(A)
FMAP
(B)
I.H.S Facility
Fam. Plan.
Services
100%
(C)
Services
90%
(D)
Total
Federal
Share
(E)
Deferral
Or
C.I.N.
Number
(F)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Type of Eligible:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21U
Total
Comp.
(A)
Federal Share
Enhanced
FMAP
FMAP
(B)
(C)
Total
Federal
Share
(D)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21U Waiv
Quarter Ended:
Total
Comp.
(A)
Federal Share
Enhanced
FMAP
FMAP
(B)
(C)
Total
Federal
Share
(D)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Type of Eligible:
1A
2
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 - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
4
Inpatient Mental Health Facility Services - Regular
Payments
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
1B
1C
1D
3A
Form CMS 64.21UP
Quarter Ended:
Fiscal Year:
Total
Comp.
(A)
Line #
Federal Share
Enhanced
FMAP
FMAP
(B)
(C)
Total
Federal
Share
(D)
Deferral
Or
C.I.N.
Number
(E)
Thursday, February 14, 2008 - 11:03 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medical Assistance Expenditures
By State Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
2
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 - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
4
Inpatient Mental Health Facility Services - Regular
Payments
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
Nursing Care Services
5
Physician And Surgical Services
6
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1
Drug Rebate - National Agreement
8A2
Drug Rebate - State Sidebar Agreement
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
1B
1C
1D
3A
Form CMS 64.21UP Waiver
Quarter Ended:
Fiscal Year:
Total
Comp.
(A)
Line #
Federal Share
Enhanced
FMAP
FMAP
(B)
(C)
Total
Federal
Share
(D)
Deferral
Or
C.I.N.
Number
(E)
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 6/30/2008
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended:
Section C
Medical Assist. Payments
Expenditures Reported for Period Total Comp. Fed. Share
By Form Number
(A)
(B)
Medicaid/CHIP
Total Comp.
(C)
State and Local Admin.
Fed. Share 20% Fed Shr Total Comp.
(D)
(E)
(F)
Fed. Share
(G)
6. Expenditures In This Quarter
From Form CMS-64.9/CMS-64.10
From Form CMS-64.9T
From Form CMS-64.21
From Form CMS-64.21U
7. Adjustments Increasing Claims For Prior Quarters:
From Form CMS 64.9P/CMS 64.10
From Form CMS-64.9TP
From Form CMS-64.21P
From Form CMS-64.21UP
8. Other Expenditures
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.21P
From Form CMS-64.21UP
9. Collections
From Form CMS-64.9 Summary
10. Adjustments Decreasing Claims For Prior Quarters:
A. Federal Audit
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS 64.21P
From Form CMS 64.21UP
10. Adjustments Decreasing Claims For Prior Quarters:
B. Other
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS 64.21P
From Form CMS 64.21UP
10.C. Adjustments Decreasing Claims For Prior Quarters:
From Form CMS-64.9O
11. Net Expenditures Reported In This Period:
Net Expenditures Reported This Period
Form CMS 64 F
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Special Issue Reporting
Program:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH
Adjustment Payments
2A
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3
Nursing Facility Services
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
5
Physicians' Services
6
Outpatient Hospital Services
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar
Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions No.
15
EPSDT Screening Services
16
Rural Health Clinic Screening
17A
Medicare Health Insurance Payments Part A Premiums
17B
Medicare Health Insurance Payments Part B Premiums
Quarter Ended:
Federal Share
IHS Facility Fam. Plan.
Total
Comp.
(A)
FMAP
(B)
Services
100%
(C)
Services
90%
(D)
Optional
Breast or
Cerv. Cancer
Services
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
(G)
17C1 120% - 134% Of Poverty
17C2 135% - 175% Of Poverty
17D
Coinsurance And Deductibles
Form CMS 64.9I
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Special Issue Reporting
Program:
18A
Quarter Ended:
Federal Share
IHS Facility Fam. Plan.
Total
Comp.
(A)
FMAP
(B)
Services
100%
(C)
Services
90%
(D)
Optional
Breast or
Cerv. Cancer
Services
(E)
0.00%
Federal
Share
(F)
Total
Federal
Share
(G)
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments:
Other
19
Home And Community-Based Services
20
Home And Community-Based Care For
Functionally Disabled Elderly
22
Programs Of All-Inclusive Care Elderly
23
Personal Care Services
24
Targeted Case Management Services
25
Primary Care Case Management Services
26
Hospice Benefits
27
Emergency Services Undocumented
Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
Form CMS 64.9I
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medical Assistance Payments
Special Issue Reporting
Program:
Total
Comp.
(A)
1A
Inpatient Hospital Services: Regular
Payments
1B
Inpatient Hospital Services: DSH
Adjustment Payments
2A
Mental Health Facility Services:
Regular Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
3
Nursing Facility Services
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
5
Physicians' Services
6
Outpatient Hospital Services
7
Prescribed Drugs
FMAP
(B)
I.H.S Fac. Fam. Pln. Opt. Brst or
Cerv.
Services Services
Cancer
Services
100%
90%
(C)
(D)
(E)
Federal
0.00%
Share
(F)
Total
Federal
Share
(G)
Deferral
Or
C.I.N.
Number
(H)
7A1 Drug Rebate Offset - National
Agreement
7A2 Drug Rebate Offset - State Sidebar
Agreement
8
Dental Services
9
Other Practitioners' Services
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions
15
EPSDT Screening Services
16
Rural Health Clinic Services
17A Medicare Health Insurance Payments:
Part A Premiums
17B Medicare Health Insurance Payments:
Part B Premiums
Form CMS 64.9PI
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medical Assistance Payments
Special Issue Reporting
Program:
Total
Comp.
(A)
FMAP
(B)
I.H.S Fac. Fam. Pln. Opt. Brst or
Cerv.
Services Services
Cancer
Services
100%
90%
(C)
(D)
(E)
Federal
0.00%
Share
(F)
Total
Federal
Share
(G)
Deferral
Or
C.I.N.
Number
(H)
17C1 Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of
Poverty
17C2 Medicare Health Insurance Payments:
Qualifying Individuals/135% - 175% of
Poverty
17D Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A Medicaid Health Insurance Payments:
Managed Care Organizations
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
18C Medicaid Health Insurance Payments:
Group Health Plan Payments
18D Medicaid Health Insurance Payments:
Coinsurance and Deductibles
18E Medicaid Health Insurance Program:
Other
19
Home And Community-Based
Services
20
Home And Community-Based Care
For Functionally Disabled Elderly
22
Programs Of All-Inclusive Care Elderly
23
Personal Care Services
24
Targeted Case Management Services
25
Primary Care Case Management
Services
26
Hospice Benefits
27
Emergency Services Undocumented
Aliens
28
Federally-Qualified Health Center
29
Other Care Services
30
Total
Form CMS 64.9PI
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Administration
Special Issue Reporting
Program:
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug
Claims System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10I
Total
Computable
(A)
FFP
Rate
Quarter Ended:
Federal Share
Federal
Federal
0.00%
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting
Program:
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs Of
In-House Activities
2B
Design Development Or Installation Of MMIS: Costs Of
Private Sector Contractors
2C
Design Development Or Installation Of MMIS: Drug Claims
System
3
Skilled Professional Medical Personnel
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private Sector
Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
6
Peer Review Organizations
7A
Third Party Liability: Recovery Procedure - Billing Offset
7B
Third Party Liability: Assignment Of Rights - Billing Offset
8
Immigration Status Verification System Costs (100% FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
Other Financial Participation
20
Total
Form CMS 64.10PI
Total
FFP
Computable Rate
(A)
Federal Share
Federal
Federal
0.00%
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Deferral Or
C.I.N.
Number
(E)
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Total Computable
(A)
Medicaid and SCHIP
Enhanced FMAP
Medicaid
%
%
(B)
(C)
Applied Against
the 20% Limit
FMAP
SCHIP Amount
(D)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Physicians' Services
Outpatient Hospital Services
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
Dental Services
Other Practitioners' Services
Clinic Services
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments Part A Premiums
Medicare Health Insurance Payments Part B Premiums
Form CMS 64.9 T
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Total Computable
(A)
Medicaid and SCHIP
Enhanced FMAP
Medicaid
%
%
(B)
(C)
Applied Against
the 20% Limit
FMAP
SCHIP Amount
(D)
120% - 134% Of Poverty
135% - 175% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Prepaid Ambulatory Health Plan
Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
Group Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Other
Home And Community-Based Services
Home And Community-Based Care For
Functionally Disabled Elderly
Programs Of All-Inclusive Care Elderly
Personal Care Services
Targeted Case Management Services
Primary Care Case Management Services
Hospice Benefits
Emergency Services Undocumented
Aliens
Federally-Qualified Health Center
Other Care Services
Total
Form CMS 64.9 T
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medicaid and
SCHIP
Medical Assistance Payments
Total
Computable
(A)
Inpatient Hospital Services - Regular
Payments
REG
Inpatient Hospital Service - DSH
Adjustment Payments
REG
Mental Health Facility Services - Regular
Payments
REG
Mental Health Facility Services - DSH
Adjustment Payments
REG
Nursing Facility Services
REG
Medicaid
Enhanced
FMAP
REG
%
INC
(B)
Applied Against
the 20% Limit
FMAP
%
(C)
SCHIP Amount
(D)
Deferral or C.I.N.
Number
(E)
INC
INC
INC
INC
INC
Intermediate Care Facility Services Mentally Retarded: Public Providers
REG
Intermediate Care Facility Services Mentally Retarded: Private Providers
REG
Physicians' Services
REG
INC
INC
INC
Outpatient Hospital Services
REG
INC
Prescribed Drugs
REG
INC
Drug Rebate Offset - National Agreement
REG
INC
Drug Rebate Offset - State Sidebar
Agreement
REG
Dental Services
REG
INC
INC
Other Practitioners' Services
REG
INC
Clinic Services
REG
INC
Laboratory And Radiological Services
REG
INC
Home Health Services
REG
INC
Sterilizations
REG
INC
Abortions No.
REG
INC
EPSDT Screening Services
REG
INC
Rural Health Clinic Screening
REG
INC
Medicare Health Insurance Payments Part A Premiums
Form CMS 64.9 TP
REG
INC
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Federal Share
Medicaid and
SCHIP
Medical Assistance Payments
Total
Computable
(A)
Medicare Health Insurance Payments Part B Premiums
REG
120% - 134% Of Poverty
REG
Medicaid
Enhanced
FMAP
REG
%
INC
(B)
Applied Against
the 20% Limit
FMAP
%
(C)
SCHIP Amount
(D)
Deferral or C.I.N.
Number
(E)
INC
INC
135% - 175% Of Poverty
REG
INC
Coinsurance And Deductibles
REG
INC
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
REG
Prepaid Ambulatory Health Plan
REG
INC
INC
Prepaid Inpatient Health Plan
REG
INC
Medicaid Health Insurance Payments:
Group Health Plan Payments
REG
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
REG
Medicaid Health Insurance Payments:
Other
REG
Home And Community-Based Services
REG
INC
INC
INC
INC
Home And Community-Based Care For
Functionally Disabled Elderly
REG
Programs Of All-Inclusive Care Elderly
REG
INC
INC
Personal Care Services
REG
INC
Targeted Case Management Services
REG
INC
Primary Care Case Management Services REG
INC
Hospice Benefits
REG
INC
Emergency Services Undocumented
Aliens
REG
Federally-Qualified Health Center
REG
INC
INC
Other Care Services
REG
INC
Total
REG
INC
Form CMS 64.9 TP
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
WaivType
Waiver Name:
WaivAdditional
Waiver Number: WaivNum
Federal Share
Medicaid and
SCHIP
Total
Computable
(A)
Inpatient Hospital Services - Regular
Payments
REG
Inpatient Hospital Service - DSH
Adjustment Payments
REG
Mental Health Facility Services - Regular
Payments
REG
Mental Health Facility Services - DSH
Adjustment Payments
REG
Nursing Facility Services
REG
Medicaid
Enhanced
FMAP
REG
%
INC
(B)
Applied Against
the 20% Limit
FMAP
%
(C)
SCHIP Amount
(D)
Deferral or C.I.N.
Number
(E)
INC
INC
INC
INC
INC
Intermediate Care Facility Services Mentally Retarded: Public Providers
REG
Intermediate Care Facility Services Mentally Retarded: Private Providers
REG
Physicians' Services
REG
INC
INC
INC
Outpatient Hospital Services
REG
INC
Prescribed Drugs
REG
INC
Drug Rebate Offset - National Agreement
REG
INC
Drug Rebate Offset - State Sidebar
Agreement
REG
Dental Services
REG
INC
INC
Other Practitioners' Services
REG
INC
Clinic Services
REG
INC
Laboratory And Radiological Services
REG
INC
Home Health Services
REG
INC
Sterilizations
REG
INC
Abortions No.
REG
INC
EPSDT Screening Services
REG
INC
Rural Health Clinic Screening
REG
INC
Form CMS 64.9 TP Waiver
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
WaivType
Waiver Name:
WaivAdditional
Waiver Number: WaivNum
Federal Share
Medicaid and
SCHIP
Total
Computable
(A)
Medicare Health Insurance Payments Part A Premiums
REG
Medicare Health Insurance Payments Part B Premiums
REG
120% - 134% Of Poverty
REG
Medicaid
Enhanced
FMAP
REG
%
INC
(B)
Applied Against
the 20% Limit
FMAP
%
(C)
SCHIP Amount
(D)
Deferral or C.I.N.
Number
(E)
INC
INC
INC
135% - 175% Of Poverty
REG
INC
Coinsurance And Deductibles
REG
INC
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
REG
Prepaid Ambulatory Health Plan
REG
INC
INC
Prepaid Inpatient Health Plan
REG
INC
Medicaid Health Insurance Payments:
Group Health Plan Payments
REG
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
REG
Medicaid Health Insurance Payments:
Other
REG
Home And Community-Based Services
REG
INC
INC
INC
INC
Home And Community-Based Care For
Functionally Disabled Elderly
REG
Programs Of All-Inclusive Care Elderly
REG
INC
INC
Personal Care Services
REG
INC
Targeted Case Management Services
REG
INC
Primary Care Case Management Services REG
INC
Hospice Benefits
REG
INC
Emergency Services Undocumented
Aliens
REG
Federally-Qualified Health Center
REG
INC
INC
Other Care Services
REG
INC
Form CMS 64.9 TP Waiver
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
WaivType
Waiver Name:
WaivAdditional
Waiver Number: WaivNum
Total
Federal Share
Medicaid and
SCHIP
Total
Computable
(A)
Medicaid
Enhanced
FMAP
REG
%
INC
(B)
Applied Against
the 20% Limit
FMAP
%
(C)
SCHIP Amount
(D)
Deferral or C.I.N.
Number
(E)
REG
INC
Form CMS 64.9 TP Waiver
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
WaivType
Waiver Name:
WaivAdditional
Waiver Number: WaivNum
Quarter Ended:
Federal Share
Total Computable
(A)
Medicaid and SCHIP
Enhanced FMAP
Medicaid
%
%
(B)
(C)
Applied Against
the 20% Limit
FMAP
SCHIP Amount
(D)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Physicians' Services
Outpatient Hospital Services
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
Dental Services
Other Practitioners' Services
Clinic Services
Laboratory And Radiological Services
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments Part A Premiums
Medicare Health Insurance Payments Part B Premiums
Form CMS 64.9 T Waiver
Thursday, February 14, 2008 - 11:04 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0067
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
WaivType
Waiver Name:
WaivAdditional
Waiver Number: WaivNum
Quarter Ended:
Federal Share
Total Computable
(A)
Medicaid and SCHIP
Enhanced FMAP
Medicaid
%
%
(B)
(C)
Applied Against
the 20% Limit
FMAP
SCHIP Amount
(D)
120% - 134% Of Poverty
135% - 175% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Prepaid Ambulatory Health Plan
Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
Group Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Other
Home And Community-Based Services
Home And Community-Based Care For
Functionally Disabled Elderly
Programs Of All-Inclusive Care Elderly
Personal Care Services
Targeted Case Management Services
Primary Care Case Management Services
Hospice Benefits
Emergency Services Undocumented
Aliens
Federally-Qualified Health Center
Other Care Services
Total
Form CMS 64.9 T Waiver
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State Children's Health Insurance Program Expenditures
For the Title XXI Program
Calculation of 10% Limit
State:
Quarter Ended:
Total Computable
Federal Share
(A)
1A
Previously Claimed Expenditures - Section 2105(a)(1)
1B
Previously Claimed Expenditures - Section 1905(u)(2) And 1905(u)(3)
2A
Expenditures Claimed In The Current Quarter - Section 2105(a)(1)
2B
Expenditures Claimed In The Current Quarter - Sections 1905(u)(2) And
1905(u)(3)
3
Total Of Column (a) Lines 1A & B And 2A & B
4
10% Limit (Divide Line 3 Column (a) By 9)
5
Total Computable - Allotment (Allotment Divided By The Enhanced FMAP)
6
10% Of The Allotment - Total Computable (10% Times Line 5)
7
10% Limit (Lesser Of Lines 4 Column (a) Or 6 Column (a))
8A
Expenditures Previously Claimed Under Section 2105(a)(2)
8B
Expenditures Currently Claimed Under Section 2105(a)(2)
9
Total Of Lines 8A And 8B
10
Amount Under/(Over) Limit (Line 7 Minus 9)
Form CMS 21 L
(B)
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 1998
(A)
(10/01/1997 - 09/30/1998)
1
FFY 1998 Allotment
2
First Quarter 1998
3
Second Quarter 1998
4
Third Quarter 1998
5
Fourth Quarter 1998
6
Excess 10% Limit
7
Unused Allotment
8
Excess Expenditures
FFY 1999
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(10/01/1998 - 09/30/1999)
1
Unused FFY 1998 Allotment
2
FFY 1999 Allotment
3
4
Excess Previously Claimed in
Prior Years
First Quarter 1999
5
Second Quarter 1999
6
Third Quarter 1999
7
Fourth Quarter 1999
8
Excess 10% Limit
9
Unused Allotment
10
Excess Expenditures
FFY 2000
1905(u)(2)/(3)
(10/01/1999 - 09/30/2000)
1
Unused FFY 1998 Allotment
2
Unused FFY 1999 Allotment
3
FFY 2000 Allotment
4
5
Excess Previously Claimed in
Prior Years
First Quarter 2000
6
Second Quarter 2000
7
Third Quarter 2000
8
Fourth Quarter 2000
9
Excess 10% Limit
10
Unused Allotment
11
Excess Expenditures
12
FFY 1998 Allotment Added to
Redistribution Pool
Form CMS 21C
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 2001
1
(A)
(10/01/2000 - 09/30/2001)
2
FFY 1998 Redistributed
Allotment
FFY 1998 Retained Amount
3
Unused FFY 1999 Allotment
4
Unused FFY 2000 Allotment
5
FFY 2001 Allotment
6
7
Excess Previously Claimed in
Prior Years
First Quarter 2001
8
Second Quarter 2001
9
Third Quarter 2001
10
Fourth Quarter 2001
11
Excess 10% Limit
12
Unused Allotment
13
Excess Expenditures
14
FFY 1999 Allotment added to
Redistribution Pool
FFY 2002
1
4
5
Unused FFY 2000 Allotment
6
Unused FFY 2001 Allotment
7
FFY 2002 Allotment
8
9
Excess Previously Claimed in
Prior Years
First Quarter 2002
10
Second Quarter 2002
11
Third Quarter 2002
12
Fourth Quarter 2002
13
Excess 10% Limit
14
Unused Allotment
15
Excess Expenditures
16
FFY 2000 Allotment added to
Redistribution Pool
3
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(10/01/2001 - 09/30/2002)
Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
FFY 1999 Redistributed
Allotment
FFY 1999 Retained Amount
2
1905(u)(2)/(3)
Form CMS 21C
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 2003
1
(A)
(10/01/2002 - 09/30/2003)
6
Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
Unused FFY 1999
Redistributed Allotment
Unused FFY 1999 Retained
Amount
FFY 2000 Redistributed
Amount
FFY 2000 Retained Allotment
7
Unused FFY 2001 Allotment
8
Unused FFY 2002 Allotment
9
FFY 2003 Allotment
10
11
Excess Previously Claimed in
Prior Years
First Quarter 2003
12
Second Quarter 2003
13
Third Quarter 2003
14
Fourth Quarter 2003
15
Excess 10% Limit
16
Unused Allotment
17
Excess Expenditures
18
FFY 2001 Allotment added to
Redistribution Pool
2
3
4
5
Form CMS 21C
1905(u)(2)/(3)
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 2004
1
(A)
(10/01/2003 - 09/30/2004)
8
Unused FFY 1998
Redistributed Allotment
Unused FFY 1998 Retained
Amount
Unused FFY 1999
Redistributed Allotment
Unused FFY 1999 Retained
Amount
Unused FFY 2000
Redistributed Allotment
Unused FFY 2000 Retained
Amount
FFY 2001 Redistributed
Amount
FFY 2001 Retained Allotment
9
Unused FFY 2002 Allotment
10
Unused FFY 2003 Allotment
11
FFY 2004 Allotment
12
13
Excess Previously Claimed in
Prior Years
First Quarter 2004
14
Second Quarter 2004
15
Third Quarter 2004
16
Fourth Quarter 2004
17
Excess 10% Limit
18
Unused Allotment
19
Excess Expenditures
20
FFY 2002 Allotment added to
Redistribution Pool
2
3
4
5
6
7
Form CMS 21C
1905(u)(2)/(3)
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 2005
1
(A)
(10/01/2004 - 09/30/2005)
4
Unused FFY 2001
Redistributed Amount
Unused FFY 2001 Retained
Allotment
FFY 2002 Redistributed
Allotment
Unused FFY 2003 Allotment
5
Unused FFY 2004 Allotment
6
FFY 2005 Allotment
7
8
Excess Previously Claimed in
Prior Years
First Quarter 2005
9
Second Quarter 2005
10
Third Quarter 2005
11
Fourth Quarter 2005
12
Excess 10% Limit
13
Unused Allotment
14
Excess Expenditures
15
FFY 2003 Allotment added to
Redistribution Pool
2
3
FFY 2006
1
1905(u)(2)/(3)
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(10/01/2005 - 09/30/2006)
2
FFY 2003 Redistributed
Allotment
FFY 2006 Shortfall
3
Unused FFY 2004 Allotment
4
Unused FFY 2005 Allotment
5
FFY 2006 Allotment
6
7
Excess Previously Claimed in
Prior Years
First Quarter 2006
8
Second Quarter 2006
9
Third Quarter 2006
10
Fourth Quarter 2006
11
Excess 10% Limit
12
Unused Allotment
13
Excess Expenditures
14
FFY 2004 Allotment added to
Redistribution Pool
Form CMS 21C
Thursday, February 14, 2008 - 11:04 AM
OMB No. 0938-0731
Expires 6/30/2008
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Allocation of Title XIX and Title XXI Expenditures
To SCHIP Fiscal Year Allotment
State:
Quarter Ended:
Federal Share Expenditures Only
Title XXI
Title XIX
20% Medicaid
FFY 2007
1
(A)
(10/01/2006 - 09/30/2007)
1905(u)(2)/(3)
PE
2105 (a)(1)(C)
2105(a)(1)(D)
Total
Balance
Unused
(B)
(C)
(D)
(E)
(F)
(G)
(H)
FFY 2004 Redistributed
Allotment
FFY 2005 Redistributed
Allotment
FFY 2007 Shortfall
2
3
4
5
Negative Adjustment FFY
2005 Allotment
Unused FFY 2005 Allotment
6
Unused FFY 2006 Allotment
7
FFY 2007 Allotment
8
9
Excess Previously Claimed in
Prior Years
First Quarter 2007
10
Second Quarter 2007
11
Third Quarter 2007
12
Fourth Quarter 2007
13
Excess 10% Limit
14
Unused Allotment
15
Excess Expenditures
16
FFY 2005 Allotment added to
Redistribution Pool
FFY 2008
1
(10/01/2007 - 09/30/2008)
2
FFY 2005 Redistributed
Allotment
Unused FFY 2006 Allotment
3
Unused FFY 2007 Allotment
4
FFY 2008 Allotment
5
6
Excess Previously Claimed in
Prior Years
First Quarter 2008
7
Second Quarter 2008
8
Third Quarter 2008
9
Fourth Quarter 2008
10
Excess 10% Limit
11
Unused Allotment
12
Excess Expenditures
13
FFY 2006 Allotment added to
Redistribution Pool
Form CMS 21C
Thursday, February 14, 2008 - 11:04 AM
| File Type | application/pdf |
| File Modified | 2008-03-27 |
| File Created | 2008-03-27 |