| Department of Health and Human Services |
|
|
|
|
|
|
|
|
OMB No. |
0938-0101 |
|
|
| Centers for Medicare & Medicaid Services |
|
|
|
|
|
|
|
|
|
|
|
|
| Medicaid Program Budget Report |
| Information - Estimated Medical Assistance by Type of Service (In Thousands) |
| State: |
|
|
|
|
|
|
|
|
Submission Date: |
|
|
|
|
|
|
|
|
Total Budgeted Services |
Total Budgeted Services |
| Type of Service |
|
|
|
|
Current Fiscal Year |
|
(1) |
|
Budget Fiscal Year |
|
(2) |
|
| Program : |
|
|
|
|
Total Computable |
Federal Share |
Total Computable |
Federal Share |
|
|
|
|
|
A |
B |
C |
|
|
D |
| 18. |
Medicaid Health Insurance Payments |
|
|
|
|
|
|
|
|
|
|
|
|
A. Managed Care Organizations (MCO) |
|
|
|
|
|
|
|
|
|
|
|
|
B.1. Prepaid Ambulatory Health Plan |
|
|
|
|
|
|
|
|
|
|
|
|
B.2. Prepaid Inpatient Health Plan |
|
|
|
|
|
|
|
|
|
|
|
|
C. Group Health Plan Payments |
|
|
|
|
|
|
|
|
|
|
|
|
D. Coinsurance and Deductibles |
|
|
|
|
|
|
|
|
|
|
|
|
E. Other |
|
|
|
|
|
|
|
|
|
|
|
| 19. |
Home & Community-Based Services |
|
|
|
|
|
|
|
|
|
|
|
| 20. |
Home & Community-Based Care for |
|
|
|
|
|
|
|
|
|
|
|
|
Functionally Disabled Elderly |
|
|
|
|
|
|
|
|
|
|
|
| 21. |
Community Supported Living Arrangements |
|
|
|
|
|
|
|
|
|
|
|
| 22. |
Programs of All-Inclusive Care for the Elderly |
|
|
|
|
|
|
|
|
|
|
|
| 23. |
Personal Care |
|
|
|
|
|
|
|
|
|
|
|
| 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. |
Subtotal |
|
|
|
|
|
|
|
|
|
|
|
| 31. |
Collections |
|
|
|
|
|
|
|
|
|
|
|
| 32. |
Prior Period Adjustments |
|
|
|
|
|
|
|
|
|
|
|
| 33. |
Total Medicaid (non-M-SCHIP) |
|
|
|
|
|
|
|
|
|
|
|
| 34. |
M-SCHIP Expansions |
|
|
|
|
|
|
|
|
|
|
|
| 35. |
Total Medicaid |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Report Date: |
|
|
|
| Form CMS-37.3I |
|
|
|
|
|
|
|
|
|
|
|
Page 2 of 2 |
| Department of Health and Human Services |
|
|
|
|
|
|
|
|
OMB No. |
0938-0101 |
|
|
| Centers for Medicare & Medicaid Services |
|
|
|
|
|
|
|
|
|
|
|
|
| Medicaid Program Budget Report |
| Information - Estimated Medical Assistance by Type of Service (In Thousands) |
| State: |
|
|
|
|
|
|
|
|
Submission Date: |
|
|
|
|
|
|
|
|
Total Budgeted Services |
Total Budgeted Services |
| Type of Service |
|
|
|
|
Current Fiscal Year |
|
(1) |
|
Budget Fiscal Year |
|
(2) |
|
| Program : |
|
|
|
|
Total Computable |
Federal Share |
Total Computable |
Federal Share |
|
|
|
|
|
A |
B |
C |
|
|
D |
| 1. |
Inpatient Hospital Services |
|
|
|
|
|
|
|
|
|
|
|
|
A. Regular Payments |
|
|
|
|
|
|
|
|
|
|
|
|
B. DSH Adjustment Payments |
|
|
|
|
|
|
|
|
|
|
|
| 2. |
Mental Health Facility Services |
|
|
|
|
|
|
|
|
|
|
|
|
A. Regular Payments |
|
|
|
|
|
|
|
|
|
|
|
|
B. DSH Adjustment Payments |
|
|
|
|
|
|
|
|
|
|
|
| 3. |
Nursing Facility Services |
|
|
|
|
|
|
|
|
|
|
|
| 4. |
Intermediate Care Facility Services |
|
|
|
|
|
|
|
|
|
|
|
|
- Mentally Retarded |
|
|
|
|
|
|
|
|
|
|
|
|
A. Public Providers |
|
|
|
|
|
|
|
|
|
|
|
|
B. Private Providers |
|
|
|
|
|
|
|
|
|
|
|
| 5. |
Physicians' Services |
|
|
|
|
|
|
|
|
|
|
|
| 6. |
Outpatient Hospital Service |
|
|
|
|
|
|
|
|
|
|
|
| 7. |
Prescribed Drugs |
|
|
|
|
|
|
|
|
|
|
|
| 7A. |
Drug Rebate Offset |
|
|
|
|
|
|
|
|
|
|
|
|
1. National Agreement |
|
|
|
|
|
|
|
|
|
|
|
|
2. 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 |
|
|
|
|
|
|
|
|
|
|
|
| 17. |
Medicare Health Insurance Payments: |
|
|
|
|
|
|
|
|
|
|
|
|
A. Part A Premiums |
|
|
|
|
|
|
|
|
|
|
|
|
B. Part B Premiums |
|
|
|
|
|
|
|
|
|
|
|
|
C. Qualifying Individuals |
|
|
|
|
|
|
|
|
|
|
|
|
D. Coinsurance and Deductibles |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Report Date: |
|
|
|
| Form CMS-37.3I |
|
|
|
|
|
|
|
|
|
|
|
Page 1 of 2 |