| MFP DEMONSTRATION FINANCIAL FORM a | ||||||||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | ||||||||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S I N Q U A R T E R _________________(ex. Q1-2007 = 1st Quarter of 2007) |
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| I. State Plan Services | TOTAL STATE SHARE | E N H A N C E D F M A P | Reg. FMAP | ADJUSTMENTS for PRIOR PERIODS**** | TOTAL FEDERAL SHARE | |||||||
| TOTAL | *Qualified HCBS | **Demonstration Services | ***Supplemental Services | |||||||||
| COMPUTABLE | ||||||||||||
| ____% | ____% | ____% | ||||||||||
| (a) | (b) | (c)' | (d) | (e) | (f) | (g) | ||||||
| 5. CLINIC SERVICES* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 6. TARGETED CASE MANAGEMENT FOR LONG TERM CARE* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 7. PACE* (PROGRAM FOR ALL INCLUSIVE CARE FOR THE ELDERLY) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 8. REHABILITATION SERVICES* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 9. HOME HEALTH SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 10. HOSPICE* | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 11. PERSONAL CARE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 12. OPTIONAL MEDICAID PLAN SERVICES* (detail on Form b) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-State Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| II. Waiver Services | (a) | (b) | (c)' | (d) | (e) | (f) | (g) | |||||
| 1. CASE MANAGEMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 2. HOMEMAKER SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 3. HOME HEALTH AIDE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 4. PERSONAL CARE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 5. ADULT DAY HEALTH | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 6. HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| a. RESIDENTIAL HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| b. DAY HABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 7. EXPANDED HABILITATION SERVICES (42 CFR §440.180(c)) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| a. PREVOCATIONAL SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| b. SUPPORTED EMPLOYMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| c. EDUCATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 8. RESPITE CARE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 9. DAY TREATMENT | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 10. PARTIAL HOSPITALIZATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 11. PSYCHOSOCIAL REHABILITATION | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 12. CLINIC SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 13. LIVE-IN CAREGIVER (42 CFR §441.303(f)(8)) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 14. CAPITATED PAYMENTS FOR LONG TERM CARE SERVICES | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| 15. OTHER* (detail on Form b) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-Waiver Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| TOTALS-Both Waiver & State Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||
| * Qualified HCBS Services are statutory HCBS waiver services that will cotinue once the MFP demonstration has ended | ||||||||||||
| ** Demonstration Services are statutory HCBS waiver services that will only be billed during an individuals 12 month transition period. | ||||||||||||
| *** Supplemental services are non-statutory HCBS waiver services that will only be available for the MFP Demonstration period. | ||||||||||||
| **** Adjustments for prior periods must match the totals on the CMS FORM 64.9PI | ||||||||||||
| MEDICAL ASSSISTANCE PAYMENT (PRIOR QUARTERS) MACROS | ||||||||||||
| MACRO | ||||||||||||
| TITLE | MACRO | DESCRIPTION | ||||||||||
| ----- | ----------------------------- | --------------------------------- | ||||||||||
| \T | {goto}Q145~{goto}TOP~ | Sets titles to allow viewing | ||||||||||
| {r}{down 5}/wtb | during input. | |||||||||||
| \Z | /wtc | Clears worksheet titles. | ||||||||||
| \I | {goto}aa1~ | Imports the matrix for printing | ||||||||||
| /fccnMATRIX~ | ||||||||||||
| {?}~ | ||||||||||||
| /wgpd | Removes the protection, temporarily | |||||||||||
| /rvaa10~e16~ | Copies the matching rates | |||||||||||
| /rvab10~k17~ | ||||||||||||
| {goto}e16~ | Centers the matching rates | |||||||||||
| {edit}{home}{del}^~ | ||||||||||||
| {goto}k17~ | ||||||||||||
| {edit}{home}{del}^~ | ||||||||||||
| /wgpe | Restores the protection | |||||||||||
| {goto}A1~ | ||||||||||||
| {calc} | ||||||||||||
| /wgpd | Copies heading from updated page 1 | |||||||||||
| /cTITLE1~TITLE2~/wgpe | to page 2. | |||||||||||
| {calc} | Prints worksheet and allows user | |||||||||||
| /ppcarPAGE1~os\015\027\048 | to compress print and print eight | |||||||||||
| {?}~mr226~p88~ | lines per inch. | |||||||||||
| qa~gprPAGE2~a~gpq | ||||||||||||
| MFP DEMONSTRATION FINANCIAL FORM b | |||||||
| Detail for Optional Medicaid State Plan Services & "Other" Waiver Services | |||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | |||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S I N Q U A R T E R _________________(ex. Q1-2007 = 1st Quarter of 2007) |
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| I. State Plan Services OPTIONAL MEDICAID PLAN SERVICES* (Detail from Form a, Line I,12) | TOTAL STATE SHARE | E N H A N C E D F M A P | Reg. FMAP | ADJUSTMENTS for PRIOR PERIODS**** | TOTAL FEDERAL SHARE | ||
| TOTAL | *Qualified HCBS | **Demonstration Services | ***Supplemental Services | ||||
| COMPUTABLE | |||||||
| _____% | _____% | _____% | |||||
| (a) | (b) | (c)' | (d) | (e) | (f) | (g) | |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| f. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| g. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| II. "Other" Waiver Services (Detail from Form a, Section II, line 15) | (a) | (b) | (c)' | (d) | (e) | (f) | (g) |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| f. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| g. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS-Waiver Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS-Both Waiver & State Plan Services | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| * Qualified HCBS Services are statutory HCBS waiver services that will cotinue once the MFP demonstration has ended | |||||||
| ** Demonstration Services are statutory HCBS waiver services that will only be billed during an individuals 12 month transition period. | |||||||
| *** Supplemental services are non-statutory HCBS waiver services that will only be available for the MFP Demonstration period. | |||||||
| **** Adjustments for prior periods must match the totals on the CMS FORM 64.9PI | |||||||
| MFP DEMONSTRATION FINANCIAL FORM c | |||||||
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | |||||||
| D E M O N S T R A T I O N E X P E N D I T U R E S B Y T Y P E O F S E R V I C E F O R T H E M O N E Y F O L L O W S T H E P E R S O N D E M O N S T R A T I O N P R O G R A M E X P E N D I T U R E S I N Q U A R T E R _________________(ex. Q1-2007 = 1st Quarter of 2007) |
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| III. Administrative | TOTAL STATE SHARE | A D M I N I S T R A T I V E F M A P | ADJUSTMENTS for PRIOR PERIODS* | TOTAL FEDERAL SHARE | |||
| TOTAL | |||||||
| COMPUTABLE | Normal Rate | SPMP | Enhanced | ||||
| 50% | 75% | 90% | |||||
| (a) | (b) | (c)' | (d) | (e) | (f) | (g) | |
| a. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| b. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| c. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| d. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| e. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| f. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| g. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| h. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| i. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| j. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| k. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| l. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| m. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| n. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| o. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| p. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| q. | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TOTALS | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Administration - Normal should include all costs that adhere to CFR Title 42, Section 433(b)(7) | |||||||
| Administrative Skilled Professional Medical Personnel (SPMP) - 75% should include all costs that adhere to CFR Title 42, Sections 433(b)(4) and 433(b)(10) | |||||||
| Administrative Enhanced - 90% should include all costs that adhere to CFR Title 42 Section 433(b)(3) | |||||||
| * Adjustments for prior periods must match the totals on the CMS FORM 64.10PI | |||||||
| DEPARTMENT OF HEALTH & HUMAN SERVICES | OMB NO. | |||||||
| CENTERS FOR MEDICARE & MEDICAID SERVICES | 0938-0067 | |||||||
| MEDICAID PROGRAM EXPENDITURE REPORT | ||||||||
| OTHER NARRATIVE EXPLANATIONS | ||||||||
| STATE | QUARTER ENDED | |||||||
| NARRATIVE | ||||||||
| FORM CMS- 64 NARRATIVE | ||||||||
| File Type | application/vnd.ms-excel |
| Last Modified By | CMS |
| File Modified | 2007-08-23 |
| File Created | 2000-12-06 |