| Department of Health and Human Services |
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OMB No. |
0938-0101 |
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| Centers for Medicare & Medicaid Services |
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| Medicaid Program Budget Report |
| Estimated Medical Assistance by Type of Service (In Thousands) |
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Submission Date: |
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Total Budgeted Services |
Total Budgeted Services |
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Current Fiscal Year |
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(1) |
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Budget Fiscal Year |
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(2) |
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Total Computable |
Federal Share |
Total Computable |
Federal Share |
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A |
B |
C |
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D |
| 18. |
Medicaid Health Insurance Payments |
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A. Managed Care Organizations (MCO) |
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B.1. Prepaid Ambulatory Health Plan |
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B.2. Prepaid Inpatient Health Plan |
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C. Group Health Plan Payments |
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D. Coinsurance and Deductibles |
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E. Other |
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| 19. |
Home & Community-Based Services |
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| 20. |
Home & Community-Based Care for |
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Functionally Disabled Elderly |
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| 21. |
Community Supported Living Arrangements |
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| 22. |
Programs of All-Inclusive Care for the Elderly |
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| 23. |
Personal Care |
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| 24. |
Targeted Case Management Services |
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| 25. |
Primary Care Case Management Services |
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| 26. |
Hospice Benefits |
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| 27. |
Emergency Services Undocumented Aliens |
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| 28. |
Federally-Qualified Health Center |
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| 29. |
Other Care Services |
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| 30. |
Subtotal |
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| 31. |
Collections |
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| 32. |
Prior Period Adjustments |
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| 33. |
Total Medicaid (non-M-SCHIP) |
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| 34. |
M-SCHIP Expansions |
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| 35. |
Total Medicaid |
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Report Date: |
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| Form CMS-37.3 |
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Page 2 of 2 |
| Department of Health and Human Services |
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|
OMB No. |
0938-0101 |
|
|
| Centers for Medicare & Medicaid Services |
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|
|
|
|
|
|
|
|
|
|
|
| Medicaid Program Budget Report |
| Estimated Medical Assistance by Type of Service (In Thousands) |
| State: |
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Submission Date: |
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|
Total Budgeted Services |
Total Budgeted Services |
| Type of Service |
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Current Fiscal Year |
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(1) |
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Budget Fiscal Year |
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(2) |
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Total Computable |
Federal Share |
Total Computable |
Federal Share |
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A |
B |
C |
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D |
| 1. |
Inpatient Hospital Services |
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A. Regular Payments |
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B. DSH Adjustment Payments |
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| 2. |
Mental Health Facility Services |
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A. Regular Payments |
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B. DSH Adjustment Payments |
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| 3. |
Nursing Facility Services |
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| 4. |
Intermediate Care Facility Services |
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- Mentally Retarded |
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A. Public Providers |
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B. Private Providers |
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| 5. |
Physicians' Services |
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| 6. |
Outpatient Hospital Service |
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| 7. |
Prescribed Drugs |
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| 7A. |
Drug Rebate Offset |
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1. National Agreement |
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2. State Sidebar Agreement |
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| 8. |
Dental Services |
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| 9. |
Other Practitioners' Services |
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| 10. |
Clinic Services |
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| 11. |
Laboratory and Radiological Services |
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| 12. |
Home Health Services |
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| 13. |
Sterilizations |
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| 14. |
Abortions |
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| 15. |
EPSDT Screening Services |
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| 16. |
Rural Health Clinic Services |
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| 17. |
Medicare Health Insurance Payments: |
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A. Part A Premiums |
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B. Part B Premiums |
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C. Qualifying Individuals |
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D. Coinsurance and Deductibles |
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Report Date: |
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| Form CMS-37.3 |
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Page 1 of 2 |