CMS-37.3I Estimated Medical Assistance by Type of Service

Medicaid Program Budget Report, and Supporting Regs.

CMS37_3I.xls

Medicaid Program Budget Report, and Supporting Regs.

OMB: 0938-0101

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Overview

CMS37_3pI2
CMS37_3Ip1


Sheet 1: CMS37_3pI2

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

Sheet 2: CMS37_3Ip1

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
File Typeapplication/vnd.ms-excel
Last Modified ByCMS
File Modified2005-03-30
File Created2001-06-05

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