CMS-37.7 Estimated Average Number of Eligibles During the Year

Department of Health and Human Services

OMB No. 0938-0101

Centers for Medicare & Medicaid Services

Medicaid Program Budget Report

Estimated Average Number of Eligibles During the Year

State:

Submission Date:

Change From

Percent Change

Change From

Percent Change

Actuals

Estimate

Estimate

Base Year To

From Base Year To

FY

(1)

To

FY

(1)

To

Eligible Categories

Base Year

FY

(1)

FY

(2)

FY

(1)

FY

(2)

FY

(2)

FY

(2)

A

B

C

D

E

F

G

Medicaid (Non-M-SCHIP)

1. Blind and Disabled

2. Aged 65 and Over (Non-Disabled)

A. Qualified Medicare Beneficiaries Only

B. Other Aged

C. Subtotal Aged 65 and Over (Non-Disabled)

3. Other Adults (Non-Disabled/Non-Aged)

A. Pregnancy Benefit Adults

B. Non--Pregnancy Benefit Adults

C. Subtotal Other Adults (Non-Disabled/Non-Aged)

4. Non-Disabled Children

A. Age Less than 1 Year

B. Age 1 to 5

C. Other Children

D. Subtotal Non-Disabled Children

5. Total Average Number of Medicaid Eligibles During the Year

M-SCHIP

6. Total Average Number of M-SCHIP Eligibiles During the Year

GRAND TOTAL

7. Total Average Number of Eligibles During the Year

Medicaid and M-SCHIP

FORM CMS-37.7

Report Date: