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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
State:
Quarter Ended: 12/31/2010
Certification
Medical Assitance Payments
Total
Federal Share
(A)
(B)
State and Local Administration
Total
Federal Share
(C)
(D)
Net Expenditures Reported In This Period (Sum
of Items 6, 7 and 8 Less 9 and 10)
I certify that:
1. I am the executive office of the state agency or his/her designate authorized by the state to submit this form.
2. This report only includes expenditures under the Medicaid program under title XIX of the Social Security Act (the Act), and as applicable
under the Children's Health Insurance Program (CHIP) under Title XXI of the Act, that are allowable in accordance with applicable
implementing federal, state, and local statutes, regulations, policies, and the state plan approved by the Secretary and in effect during the
Quarter Ended indicated above under Title XIX of the Act for the Medicaid program, and as applicable, under Title XXI of the ACT for the CHIP.
3. The expenditures included in this report are based on the state's accounting of actual recorded expenditures, and are not based on
estimates.
4. The required amount of state and/or local funds were available and used to match the state's allowable expenditures included in this report,
and such state and/or local funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures.
5. Federal matching funds are not being claimed on this report to match any expenditure under any Medicaid and/or CHIP state plan
amendment that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the Quarter Ended.
6. The information shown above and on the Form CMS-64 Summary Sheet and the Supporting Schedules is correct to the best of my
knowledge and belief.
Date:
Signature:
Title:
User Performing Certification:
Footnotes:
Form CMS 64 Certification
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Medicaid
ARRA
Total
Federal
Federal
Federal
Computable
Share
Share
Share
(A)
(B)
(C)
(D)
1
2
3.A.
3.B.
10.C.
10.D.
Adjustments/Decreasing Prior Qtrs - Perm
11
Net Expenditures Reported In This Period
(Sum of Items 6, 7 and 8 Less 9 and 10)
6
7
8
9.A.
9.B.
9.C.1.
9.C.2.
9.D.
9.E.
10.A.
10.B.
Total
Computable
(E)
Federal
Share
(F)
Section A: Quarterly Status of Funding
Awards Received During The Quarter For
The Quarter Being Reported And Prior
Quarters
Awards Received During The Quarter For
Subsequent Quarters
Interest: Received On Medicaid Recoveries
Interest: Assessed On Disallowances
Medicare Overpayment Collection Under
Sec. 1914 and 42 CFR 447.30
Other
Section B: Expenditures Reported for
the Period
Expenditures In This Quarter
Adjustments Increasing Claims For Prior
Quarters
Other Expenditures
Collections: Third Party Liability
Collections: Probate
Recoveries: Fraud, Waste and Abuse
Efforts
Recoveries: OIG Compliant False Claims
Act
Collections: Other
Misc.
Adjustments Decreasing Claims For Prior
Quarters: Federal Audit
Adjustments Decreasing Claims For Prior
Quarters: Other
Adjustments Decreasing Claims For Prior
Quarters: Overpayment Adjustments
(Attach 64.9O)
4
5
State and Local
Administration
Form CMS 64 Summary
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
6b
7
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Federal Prompt
Srvcs (ENH Srvcs (IHS
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total Federal
Share
(G)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
Form CMS 64.9 BASE
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Federal Prompt
Srvcs (ENH Srvcs (IHS
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total Federal
Share
(G)
7A1
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A
Payments
Other Practitioners Services 9B
Supplemental Payments
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions No.
15
EPSDT Screening Services
16
Rural Health Clinic Screening
Medicare Health Insurance Payments 17A Part A Premiums
Medicare Health Insurance Payments 17B Part B Premiums
17C1 120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
Form CMS 64.9 BASE
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
18C
18D
18E
19A
19B
19C
22
23A
23B
24A
24B
25
26
Total Federal
Share
(G)
Medicaid Health Insurance Payments:
Group Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Other
Home and Community-Based Services Regular Payment (Waiver)
Home and Community-Based Services State Plan 1915(i) Only Payment
Home and Community-Based Services State Plan 1915(j) Only Payment
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
32
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
33
Prosthetic Devices, Dentures, Eyeglasses
27
28
29
30
31
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Federal Prompt
Srvcs (ENH Srvcs (IHS
Other % Share Payment
Rate)
Rate)
(E)
(F)
Form CMS 64.9 BASE
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
34
35
36
37
38
39
40
41
42
43
44
49
50
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Federal Prompt
Srvcs (ENH Srvcs (IHS
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total Federal
Share
(G)
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9 BASE
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Name:
Total
Computable
Waiver
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal
Share
Other %
Federal Prompt
Share Payment
(F)
(G)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Form CMS 64.9 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Name:
Total
Computable
Waiver
(A)
6b
7
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal
Share
Other %
Federal Prompt
Share Payment
(F)
(G)
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A
Payments
Other Practitioners Services - Supplemental
9B
Payments
10
Clinic Services
11
Laboratory And Radiological Services
12
Home Health Services
13
Sterilizations
14
Abortions No.
15
EPSDT Screening Services
16
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part
17A A Premiums
Medicare Health Insurance Payments - Part
17B B Premiums
17C1 120% - 134% Of Poverty
Form CMS 64.9 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Name:
Total
Computable
Waiver
(A)
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal
Share
Other %
Federal Prompt
Share Payment
(F)
(G)
17D
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22
Programs Of All-Inclusive Care Elderly
23A
23B
24A
24B
25
26
27
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Form CMS 64.9 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Name:
Total
Computable
Waiver
(A)
28
29
30
31
32
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
35
36
37
38
39
Diagnostic Screening & Preventive Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
40
41
42
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w/ Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
43
44
49
50
Form CMS 64.9 WAIVER
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal
Share
Other %
Federal Prompt
Share Payment
(F)
(G)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
Family
Planning
Services
FMAP
90%
(B)
(C)
I.H.S
Services
100%
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal Deferral or
Share CIN Number
Other %
Federal Prompt
Share Payment
(F)
(G)
(H)
Inpatient Hospital Services: Regular
Payments
Inpatient Hospital Services: DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Form CMS 64.9P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Total
Computable
(A)
6b
7
Family
Planning
Services
FMAP
90%
(B)
(C)
I.H.S
Services
100%
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal Deferral or
Share CIN Number
Other %
Federal Prompt
Share Payment
(F)
(G)
(H)
Outpatient Hospital Services - Supplemental
Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services - Supplemental
9B Payments
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
Medicare Health Insurance Payments: Part
17A A Premiums
Medicare Health Insurance Payments: Part
17B B Premiums
Form CMS 64.9P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Total
Computable
(A)
Family
Planning
Services
FMAP
90%
(B)
(C)
I.H.S
Services
100%
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal Deferral or
Share CIN Number
Other %
Federal Prompt
Share Payment
(F)
(G)
(H)
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of
17C1 Poverty
Medicare Health Insurance Payments:
17D Coinsurance and Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations
18B1 Prepaid Ambulatory Health Plan
18B2 Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance and Deductibles
18E Medicaid Health Insurance Program: Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22 Programs Of All-Inclusive Care Elderly
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
Primary Care Case Management Services
Form CMS 64.9P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Total
Computable
(A)
26
32
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
35
36
37
38
39
Diagnostic Screening & Preventive Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
40
41
42
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
27
28
29
30
31
43
44
49
50
Form CMS 64.9P
Family
Planning
Services
FMAP
90%
(B)
(C)
I.H.S
Services
100%
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Rate)
Rate)
(E)
Total
Federal Deferral or
Share CIN Number
Other %
Federal Prompt
Share Payment
(F)
(G)
(H)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Federal Prompt
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total
Federal Deferral or
Share CIN Number
(G)
(H)
Inpatient Hospital Services: Regular
Payments
Inpatient Hospital Services: DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Form CMS 64.9P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Federal Prompt
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total
Federal Deferral or
Share CIN Number
(G)
(H)
Outpatient Hospital Services 6b Supplemental Payments
7
Prescribed Drugs
7A1 Drug Rebate - National Agreement
7A2 Drug Rebate - State Sidebar Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services 9B Supplemental Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health
13 Sterilizations
14 Abortions
15 EPSDT Screening Services
16 Rural Health Clinic Services
Medicare Health Insurance Payments: Part
17A A Premiums
Medicare Health Insurance Payments: Part
17B B Premiums
Form CMS 64.9P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Federal Prompt
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total
Federal Deferral or
Share CIN Number
(G)
(H)
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of
17C1Poverty
Medicare Health Insurance Payments:
17D Coinsurance and Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance and Deductibles
18E Medicaid Health Insurance Program: Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22 Programs Of All-Inclusive Care Elderly
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
Form CMS 64.9P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
49
50
Family
Planning
I.H.S
Services Services
FMAP
90%
100%
(B)
(C)
(D)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Srvcs (ENH Srvcs (IHS
Federal Prompt
Other % Share Payment
Rate)
Rate)
(E)
(F)
Total
Federal Deferral or
Share CIN Number
(G)
(H)
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medicaid Overpayment Adjustment
State:
Quarter Ended: 12/31/2010
Overpayment Activity
Total
Computable
(A)
1
Overpayments Not Collected Or Adjusted
But Refunded Because Of The Expiration
Of The 60-Day Time Limit
2
Decreasing Adjustments To Amounts
Previously Reported On Line 1
3
Subtotal
4
Previously Reported Overpayments To
Providers Certified This Quarter As
Bankrupt Or Out Of Business
5
Total Overpayment Adjustments This
Quarter
Form CMS 64.9O
2008
(B)
Total Federal Share
Federal Share
2009
2010
(C)
(D)
2011
(E)
(F)
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medicaid Overpayment Adjustment
State:
Quarter Ended: 12/31/2010
PERM Activity
Total
Computable
(A)
1
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 60Day Time Limit
2
Decreasing Adjustments To Amounts Previously
Reported On Line 1
3
Subtotal
4
5
2008
(B)
Total Federal
Federal Share
PERM-Identified Overpayments
2009
2010
(C)
(D)
2011
(E)
(F)
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
ARRA:
Previously Reported Overpayments To Providers
Certified This Quarter As Bankrupt Or Out Of
Business
Total Overpayment Adjustments This Quarter
Form CMS 64.9OPerm
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Third Party Liability Collections and Cost Avoidance
State:
Quarter Ended: 12/31/2010
Total
Computable
(A)
Medicaid Federal
Share
(B)
ARRA Federal
Share
(C)
Federal Share
(D)
A. Third Party Liability Collections
Amount Of Third Liabilty Collections Made
In This Quarter By Source: Medicare Title
1.a. XVIII
b.1. Other Collections: Health Insurance
2
Other Collections: Casualty Insurance
Total Collections Under Cooperative
Agreements Section 1903(p) And
c. Assignment of Right Section 1912
Total Collections: Less Excess Paid To
1 Individuals
Net Collections To Reimburse State Title
2 XIX Medical Payments
Less 15% Incentive Actually Paid Under
3 Section 1903(p)(1)
Net Federal Share Of Collections
4 Reportable
2
Total Third Party Liabilty Collections
B. Cost Avoidance
1
Medicare Title XVIII
2
Health Insurance
3
Other Cost Avoidance
Form CMS 64.9A
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Total
Computable
FPP Rate
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
5C
6
7A
7B
8
Federal Share
Federal Share
Other %
(B)
Total Federal
Share
Federal Share
(C)
(D)
Family Planning
Design Development Or Installation Of
MMIS: Cost of In-House Activities
Design Development Or Installation Of
MMIS: Cost of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Costs of
In-House Activities Plus State Agencies
And Institutions
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Form CMS 64.10 Base
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Total
Computable
FPP Rate
(A)
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Federal Share
Federal Share
Other %
(B)
Total Federal
Share
Federal Share
(C)
(D)
Nurse Aide Training Costs
Preadmission Screening Costs
Resident Review Activities Costs
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary 90%
TANF Secondary 75%
External Review
Enrollment Brokers
School Based Administration
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs (State Level)
Translation and Interpretation
Health Information Technology
Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
Form CMS 64.10 Base
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Total
Computable
FPP Rate
(A)
29
30
Federal Share
Federal Share
Other %
(B)
Total Federal
Share
Federal Share
(C)
(D)
Other Financial Participation
Total
Form CMS 64.10 Base
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
Federal
Share
FPP Rate
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
5C
6
Total Federal
Share
Federal Share
(B)
Federal
Share
Other %
(C)
(D)
Family Planning
Design Development Or Installation Of
MMIS: Cost of In-House Activities
Design Development Or Installation Of
MMIS: Cost of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Costs of
In-House Activities Plus State Agencies
And Institutions
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Form CMS 64.10 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
Federal
Share
FPP Rate
(A)
7A
7B
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Total Federal
Share
Federal Share
(B)
Federal
Share
Other %
(C)
(D)
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Nurse Aide Training Costs
Preadmission Screening Costs
Resident Review Activities Costs
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary 90%
TANF Secondary 75%
External Review
Enrollment Brokers
School Based Administration
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs
Translation and Interpretation
Health Information Technology
Administration
Form CMS 64.10 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
Federal
Share
FPP Rate
(A)
Total Federal
Share
Federal Share
(B)
Federal
Share
Other %
(C)
(D)
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
29 Other Financial Participation
30 Total
Form CMS 64.10 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Total
Computable
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
5C
6
Deferral or CIN
Number
Federal Share
Federal
Share
FFP Rate
(B)
Federal
Share
Other %
(C)
Total
Federal
Share
(D)
(E)
Family Planning
Design Development Or Installation Of
MMIS: Costs Of In-House Activities
Design Development Or Installation Of
MMIS: Costs Of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Cost Of
In-House Activities
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Form CMS 64.10P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Total
Computable
(A)
7A
7B
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Deferral or CIN
Number
Federal Share
Federal
Share
FFP Rate
(B)
Federal
Share
Other %
(C)
Total
Federal
Share
(D)
(E)
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)
External Review
Enrollment Brokers
School Based Administration
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs
Translation and Interpretation
Form CMS 64.10P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Total
Computable
(A)
24
Deferral or CIN
Number
Federal Share
Federal
Share
FFP Rate
(B)
Federal
Share
Other %
(C)
Total
Federal
Share
(D)
(E)
Health Information Technology
Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
29 Other Financial Participation
30 Total
Form CMS 64.10P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
5C
Federal Share
Federal
Federal
Share Other % Share
FFP Rate
(B)
(C)
Total
Federal
Share
Deferral or
CIN Number
(D)
(E)
Family Planning
Design Development Or Installation Of
MMIS: Costs Of In-House Activities
Design Development Or Installation Of
MMIS: Costs Of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Cost Of
In-House Activities
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Form CMS 64.10P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
(A)
6
7A
7B
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Federal Share
Federal
Federal
Share Other % Share
FFP Rate
(B)
(C)
Total
Federal
Share
Deferral or
CIN Number
(D)
(E)
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)
External Review
Enrollment Brokers
School Based Administration
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs
Form CMS 64.10P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
(A)
23
24
Federal Share
Federal
Federal
Share Other % Share
FFP Rate
(B)
(C)
Total
Federal
Share
Deferral or
CIN Number
(D)
(E)
Translation and Interpretation
Health Information Technology
Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
29 Other Financial Participation
30 Total
Form CMS 64.10P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Provider-Related Donations And
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Summary Total of Receipts From Form CMS 64.11 A
State:
Quarter Ended:
Plan Name
(A)
Donations
1
Donations - Medicaid
1.A. Donations - CHIP
2
Donations- Outstationed Eligibility Workers - Medicaid
2.A. Donations- Outstationed Eligibility Workers - CHIP
Taxes
3
Taxes
Fees
4
Fees
Assessments
5
Assessments
Totals
6
Total Donations (Lines 1 + 1.A. + 2 + 2.A.)
7
Total Taxes, Fees, and Assessments (Lines 3 + 4 + 5)
Form CMS 64.11
Receipts
(B)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Provider-Related Donations And
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Actual Receipts By Plan Name
Code:
1. Donations - Medicaid
1.A. Donations - CHIP
2. Donations - Outstanding Eligibility Workers - Medicaid
2.A. Donations - Outstanding Eligibility Workers - CHIP
3. Taxes
4. Fees
5. Assessments
Code
(A)
Form CMS 64.11A
Plan Name
(B)
Receipts
(C)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
FFY 2000 (10/01/1999 - 09/30/2000)
1
FFY 2000 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2000 Allotment
FFY 2001 (10/01/2000 - 09/30/2001)
1
FFY 2001 Allotment
2
Amount Previously Reported - Title XIX
2A
3
3A
4
4A
5
5A
6
6A
7
7A
8
8A
Amount Previously Reported - CHIP Related - PE
Line 6 - Title XIX
Line 6 - CHIP Related - PE
Line 7 - Title XIX
Line 7 - CHIP Related - PE
Line 8 - Title XIX
Line 8 - CHIP Related - PE
Line 10 - Title XIX
Line 10 - CHIP Related - PE
Subtotal - Title XIX
Subtotal - CHIP Related - PE
Total To Date - Title XIX
Total - CHIP Related - PE
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
9
Unused FFY 2001 Allotment
FFY 2002 (10/01/2001 - 09/30/2002)
1
FFY 2002 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2002 Allotment
FFY 2003 (10/01/2002 - 09/30/2003)
1
FFY 2003 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
8A Total - CHIP Related - PE
9
Unused FFY 2003 Allotment
FFY 2004 (10/01/2003 - 09/30/2004)
1
FFY 2004 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2004 Allotment
FFY 2005 (10/01/2004 - 09/30/2005)
1
FFY 2005 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2005 Allotment
FFY 2006 (10/01/2005 - 09/30/2006)
FFY 2006 Allotment
1
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2006 Allotment
FFY 2007 (10/01/2006 - 09/30/2007)
1
FFY 2007 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2007 Allotment
FFY 2008 (10/01/2007 - 09/30/2008)
1
FFY 2008 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2008 Allotment
FFY 2009 (10/01/2008 - 09/30/2009)
1
FFY 2009 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2009 Allotment
10 Amount Over FFY 2009 Allotment
11 Additional Increased FFY 2009 DSH Allotment
12 Amount Previously Reported - Inc Allotment
13 Increased Amount Applied to Allotment (roll frwd)
14 Reduction to Increased Allotment (roll back)
15 Unused FFY 2009 Increased Allotment
16 Excess Expenditures
FFY 2010 (10/01/2009 - 09/30/2010)
1
FFY 2010 Allotment
2
Amount Previously Reported - Title XIX
2A Amount Previously Reported - CHIP Related - PE
3
Line 6 - Title XIX
3A Line 6 - CHIP Related - PE
4
Line 7 - Title XIX
4A Line 7 - CHIP Related - PE
5
Line 8 - Title XIX
5A Line 8 - CHIP Related - PE
6
Line 10 - Title XIX
6A Line 10 - CHIP Related - PE
7
Subtotal - Title XIX
7A Subtotal - CHIP Related - PE
8
Total To Date - Title XIX
8A Total - CHIP Related - PE
9
Unused FFY 2010 Allotment
10 Amount Over FFY 2009 Allotment
11 Additional Increased FFY 2010 DSH Allotment
12 Amount Previously Reported - Inc Allotment
13 Increased Amount Applied to Allotment (roll frwd)
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended: 12/31/2010
Inpatient Hospital
Total
Federal Share
Computable
(A)
14
15
16
(B)
Mental Health Facility Services
Total
Federal Share
Computable
(C)
(D)
Total
Total
Federal Share
Computable
(E)
(F)
Reduction to Increased Allotment (roll back)
Unused FFY 2010 Increased Allotment
Excess Expenditures
Form CMS 64.9D
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medicaid Drug Rebate Schedule
State:
Quarter Ended: 12/31/2010
Quarter
Ending
09/30/2010
Quarter
Ending
06/30/2010
(A)
(B)
Total Computable
Quarter
Quarter
Ending
Ending
03/31/2010 12/31/2010
Drug Rebate
1
Balance Of The Beginning Of The Quarter
2
3
4
Adjustments To Previously Reported Rebates
From Drug Labelers Included In Line 1
Rebates Invoiced In This Quarter
Subtotal
(C)
(D)
Quarter
Ending
09/30/2009
and Prior
Total
(E)
(F)
5
Rebates Reported On This Expenditure Report
6
Balance As Of The End Of The Quarter
FOOTNOTE:
Form CMS 64.9R
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medicaid Program Expenditure Report
Other Narrative Explanations
State:
Quarter Ended: 12/31/2010
Narrative
Form CMS 64 Narrative
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Total
Computable
(A)
1A
1B
1C
1D
2
2A
3
3A
4
5
6
Federal Share
FMAP
Percent
(B)
I.H.S. Facility
Services 100%
(C)
Family Planning
Services 90%
(D)
Total Federal
Prompt
Pay
(E)
(F)
Premiums: Up To 150% of Poverty Level Gross Premiums Paid
Premiums Up To 150% of Poverty Level:
Cost Sharing Offsets
Premiums Over 150% of Poverty Level Gross Premiums Paid
Premiums Over 150% of Poverty Level:
Cost Sharing Offsets
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustment Payments
Nursing Care Services
Physician and Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
Form CMS 64.21
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Total
Computable
(A)
Federal Share
FMAP
Percent
(B)
I.H.S. Facility
Services 100%
(C)
Family Planning
Services 90%
(D)
Total Federal
Prompt
Pay
(E)
(F)
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory and Radiological Services
15
16
17
18
19
20
21
22
23
24
25
26
Durable and Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home and Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Total
Form CMS 64.21
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
3A
4
5
6
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level Cost Sharing Offset
Premiums Over 150% Of Poverty Level Gross Premiums Paid
Premiums Over 150% Of Poverty Level Cost Sharing Offset
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustments Payments
Nursing Care Services
Physician and Surgical Services
Outpatient Hospital Services
7
8
Outpatient Mental Health Facility Services
Prescribed Drugs
1A
1B
1C
1D
2
2A
3
Form CMS 64.21P
Federal Share
I.H.S.
Family
FMAP Services Planning Prompt
Percent
100%
90%
Pay
(B)
(C)
(D)
(E)
Deferral
Total Federal Disallowance or
Share
C.I.N. No.
(F)
(G)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
Federal Share
I.H.S.
Family
FMAP Services Planning Prompt
Percent
100%
90%
Pay
(B)
(C)
(D)
(E)
Deferral
Total Federal Disallowance or
Share
C.I.N. No.
(F)
(G)
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory and Radiological services
15
16
17
18
19
20
21
Durable and Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home and Community-Based Services
Form CMS 64.21P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
22
23
24
25
26
27
28
Federal Share
I.H.S.
Family
FMAP Services Planning Prompt
Percent
100%
90%
Pay
(B)
(C)
(D)
(E)
Deferral
Total Federal Disallowance or
Share
C.I.N. No.
(F)
(G)
Hospice
Medical Transportation
Case Management
Other Services
Balance
Collections
Total
Form CMS 64.21P
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
1A
1B
1C
1D
2
2A
3
3A
4
5
6
Total Federal
Share
Federal Share
FMAP
Percent
(B)
I.H.S. Services
Family
100%
Planning 90%
(C)
(D)
Prompt
Pay
(E)
(F)
Premiums: Up To 150% of Poverty Level Gross Premiums Paid
Premiums Up To 150% of Poverty Level:
Cost Sharing Offsets
Premiums Over 150% of Poverty Level Gross Premiums Paid
Premiums Over 150% of Poverty Level:
Cost Sharing Offsets
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustment Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
Form CMS 64.21 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
Total Federal
Share
Federal Share
FMAP
Percent
(B)
I.H.S. Services
Family
100%
Planning 90%
(C)
(D)
Prompt
Pay
(E)
(F)
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory And Radiological Services
Durable And Disposable Medical
15 Equipment
16 Family Planning
17 Abortions
18 Screening Services
19 Home Health
20 Medicare Payments
21 Home And Community-Based Services
22 Hospice
23 Medical Transportation
24 Case Management
Form CMS 64.21 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
25
26
Total Federal
Share
Federal Share
FMAP
Percent
(B)
I.H.S. Services
Family
100%
Planning 90%
(C)
(D)
Prompt
Pay
(E)
(F)
Other Services
Total
Form CMS 64.21 WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
3A
4
5
6
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level Cost Sharing Offset
Premiums Over 150% Of Poverty Level Gross Premiums Paid
Premiums Over 150% Of Poverty Level Cost Sharing Offset
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustments Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
1A
1B
1C
1D
2
2A
3
Form CMS 64.21P WAIVER
Federal Share
I.H.S.
Family
FMAP Services Planning
Percent
100%
90%
(B)
(C)
(D)
Prompt
Pay
(E)
Total
Federal
Share
Deferral
Disallowance
or C.I.N. No.
(G)
(H)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
Federal Share
I.H.S.
Family
FMAP Services Planning
Percent
100%
90%
(B)
(C)
(D)
Prompt
Pay
(E)
Total
Federal
Share
Deferral
Disallowance
or C.I.N. No.
(G)
(H)
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory And Radiological services
Durable And Disposable Medical
15 Equipment
16 Family Planning
17 Abortions
18 Screening Services
19 Home Health
Form CMS 64.21P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
20
21
22
23
24
25
26
27
28
Federal Share
I.H.S.
Family
FMAP Services Planning
Percent
100%
90%
(B)
(C)
(D)
Prompt
Pay
(E)
Total
Federal
Share
Deferral
Disallowance
or C.I.N. No.
(G)
(H)
Medicare Payments
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Balance
Collections
Total
Form CMS 64.21P WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Total
Computable
(A)
1A
1B
1C
1D
2
2A
3
3A
4
5
6
Federal Share
FMAP Enhanced
Percent
FMAP
(B)
(C)
Total Federal
Share
(D)
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level Cost Sharing Offsets
Premiums Over 150% Of Poverty Level Gross Premiums Paid
Premiums Over 150% Of Poverty Level Cost Sharing Offsets
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustment Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory And Radiological Services
Form CMS 64.21U
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Total
Computable
(A)
15
16
17
18
19
20
21
22
23
24
25
26
Federal Share
FMAP Enhanced
Percent
FMAP
(B)
(C)
Total Federal
Share
(D)
Durable And Disposable Medical
Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Total
Form CMS 64.21U
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended: 12/31/2010
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
(A)
1A
1B
1C
1D
2
2A
3
3A
4
5
6
7
8
8A1
8A2
8A3
8A4
8A5
8A6
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Federal Share
FMAP
Percent
(B)
Enhanced
FMAP
(C)
Total
Federal
Share
(D)
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
Premiums Over 150% Of Poverty Level - Cost Sharing
Offsets
Inpatient Hospital Services - Regular Payments
Inpatient Hospital Services - DSH Adjustments Payments
Inpatient Mental Health Facility Services - Regular
Payments
Inpatient Mental Health Facility Services - DSH Adjustment
Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
Outpatient Mental Health Facility Services
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service - 100%
Increased ACA OFFSET - MCO - 100%
Dental Services
Vision Services
Other Practitioners' Services
Clinic Services
Therapy Services
Laboratory And Radiological Services
Durable And Disposable Medical Equipment
Family Planning
Abortions
Screening Services
Home Health
Medicare Payments
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Total
Form CMS 64.21U Waiver
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Qtr / Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
1A
1B
1C
1D
2
2A
3
3A
4
5
6
Federal Share
FMAP Enhanced
Percent
FMAP
(B)
(C)
Total Federal
Share
Deferral or
C.I.N
Number
(D)
(E)
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level Cost Sharing Offsets
Premiums Over 150% Of Poverty Level Gross Premiums Paid
Premiums Over 150% Of Poverty Level Cost Sharing Offsets
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustment Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory And Radiological Services
Durable And Disposable Medical
15 Equipment
16 Family Planning
17 Abortions
18 Screening Services
19 Home Health
20 Medicare Payments
Form CMS 64.21UP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Qtr / Fiscal Year:
Line #
Type of Eligible:
21
22
23
24
25
26
27
28
Total
Computable
Federal Share
FMAP Enhanced
Percent
FMAP
Total Federal
Share
Deferral or
C.I.N
Number
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Balance
Collections
Total
Form CMS 64.21UP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Qtr / Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
1A
1B
1C
1D
2
2A
3
3A
4
5
6
Total
Computable
(A)
Federal Share
Total Federal
Share
Deferral or
C.I.N
Number
FMAP Enhanced
Percent
FMAP
(B)
(C)
(D)
(E)
Premiums Up To 150% Of Poverty Level Gross Premiums Paid
Premiums Up To 150% Of Poverty Level Cost Sharing Offsets
Premiums Over 150% Of Poverty Level Gross Premiums Paid
Premiums Over 150% Of Poverty Level Cost Sharing Offsets
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Services - DSH
Adjustments Payments
Inpatient Mental Health Facility Services Regular Payments
Inpatient Mental Health Facility Services DSH Adjustment Payments
Nursing Care Services
Physician And Surgical Services
Outpatient Hospital Services
7
Outpatient Mental Health Facility Services
8
Prescribed Drugs
8A1 Drug Rebate - National Agreement
8A2 Drug Rebate - State Sidebar Agreement
8A3 MCO - National Agreement
8A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 8A5 100%
8A6 Increased ACA OFFSET - MCO - 100%
9
Dental Services
10 Vision Services
11 Other Practitioners' Services
12 Clinic Services
13 Therapy Services
14 Laboratory And Radiological Services
Durable And Disposable Medical
15 Equipment
16 Family Planning
17 Abortions
18 Screening Services
19 Home Health
Form CMS 64.21UP Waiver
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
State:
Quarter Ended: 12/31/2010
Qtr / Fiscal Year:
Line #
20
21
22
23
24
25
26
27
28
Type of Eligible:
Waiver Type:
Waiver Number:
Waiver Name:
Medicare Payments
Home And Community-Based Services
Hospice
Medical Transportation
Case Management
Other Services
Balance
Collections
Total
Form CMS 64.21UP Waiver
Total
Computable
Federal Share
Total Federal
Share
Deferral or
C.I.N
Number
FMAP Enhanced
Percent
FMAP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended: 12/31/2010
Section C
Expenditures Reported by Period
By Form Number
6.A.
From Form CMS-64.9/CMS-64.10
6.A.1.
From Form CMS-64.9T
6.B.
From Form CMS-64.21
6.C.
From Form CMS-64.21U
7.A.
From Form CMS 64.9P/CMS 64.10
7.A.1.
From Form CMS-64.9TP
7.B.
From Form CMS-64.21P
7.C.
From Form CMS-64.21UP
8.A.
From Form CMS 64.9P/CMS 64.10P
8.A.1.
From Form CMS-64.9TP
8.B.
From Form CMS-64.21P
8.C.
From Form CMS-64.21UP
9
From Form CMS-64.9 Summary
10.A.1.
From Form CMS 64.9P/CMS 64.10P
10.A.1.a From Form CMS-64.9TP
10.A.2.
From Form CMS 64.21P
10.A.3.
From Form CMS 64.21UP
10.B.1.
From Form CMS 64.9P/CMS 64.10P
10.B.1.a From Form CMS-64.9TP
10.B.2.
From Form CMS 64.21P
10.B.3.
From Form CMS 64.21UP
10.C.
From Form CMS-64.9O/64.9O ARRA
10.D.
From Form CMS-64.9OPerm
11
Net Expenditures Reported This Period
Form CMS 64.F
Medical Assist.
Payments
Total
Computable
(A)
Medicaid / CHIP
State and Local
Admin.
20%
Federal
Total
Federal Federal
Total
Federal
Share Computable Share
Share Computable Share
(B)
(C)
(D)
(E)
(F)
(G)
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Family
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
Federal
FMAP Services Services
Rate)
Rate)
Other % Share
(B)
(C)
(D)
(E)
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Form CMS 64.9I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
5A
6A
6b
7
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Family
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
Federal
FMAP Services Services
Rate)
Rate)
Other % Share
(B)
(C)
(D)
(E)
(F)
Total
Federal
Share
(G)
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services 9B Supplemental Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions No.
Form CMS 64.9I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Family
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
Federal
FMAP Services Services
Rate)
Rate)
Other % Share
(B)
(C)
(D)
(E)
(F)
Total
Federal
Share
(G)
15
16
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part
17A A Premiums
Medicare Health Insurance Payments - Part
17B B Premiums
17C1120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22 Programs Of All-Inclusive Care Elderly
Form CMS 64.9I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Family
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
Federal
FMAP Services Services
Rate)
Rate)
Other % Share
(B)
(C)
(D)
(E)
(F)
Total
Federal
Share
(G)
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Form CMS 64.9I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
40
41
42
43
44
49
50
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Cancer
Cancer
Family
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
Federal
FMAP Services Services
Rate)
Rate)
Other % Share
(B)
(C)
(D)
(E)
(F)
Total
Federal
Share
(G)
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Family
Cancer
Cancer
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
FMAP Services Services
Rate)
Rate)
(B)
(C)
(D)
(E)
Total
Federal Deferral or
Share CIN Number
Federal
Other % Share
(F)
(G)
(H)
Inpatient Hospital Services: Regular
Payments
Inpatient Hospital Services: DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services: Regular
Payments
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Mentally Retarded: Supplemental
Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Form CMS 64.9PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
6A
6b
7
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Family
Cancer
Cancer
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
FMAP Services Services
Rate)
Rate)
(B)
(C)
(D)
(E)
Total
Federal Deferral or
Share CIN Number
Federal
Other % Share
(F)
(G)
(H)
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services 9B Supplemental Payments
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
Form CMS 64.9PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Family
Cancer
Cancer
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
FMAP Services Services
Rate)
Rate)
(B)
(C)
(D)
(E)
Total
Federal Deferral or
Share CIN Number
Federal
Other % Share
(F)
(G)
(H)
Medicare Health Insurance Payments: Part
17A A Premiums
Medicare Health Insurance Payments: Part
17B B Premiums
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of
17C1 Poverty
Medicare Health Insurance Payments:
17D Coinsurance and Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance and Deductibles
18E Medicaid Health Insurance Program: Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22 Programs Of All-Inclusive Care Elderly
Form CMS 64.9PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Family
Cancer
Cancer
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
FMAP Services Services
Rate)
Rate)
(B)
(C)
(D)
(E)
Total
Federal Deferral or
Share CIN Number
Federal
Other % Share
(F)
(G)
(H)
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Form CMS 64.9PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Special Issue Reporting Program
Total
Computable
(A)
40
41
42
43
44
49
50
Federal Share
Opt. Breast Opt. Breast
or Cervical or Cervical
Family
Cancer
Cancer
I.H.S.
Planning Srvcs (ENH Srvcs (IHS
FMAP Services Services
Rate)
Rate)
(B)
(C)
(D)
(E)
Total
Federal Deferral or
Share CIN Number
Federal
Other % Share
(F)
(G)
(H)
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Administration
Special Issue Reporting Program
Total
Computable
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
5C
6
Federal Share
FPP
Federal Other % Federal
Rate
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Family Planning
Design Development Or Installation Of
MMIS: Cost of In-House Activities
Design Development Or Installation Of
MMIS: Cost of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Costs of
In-House Activities Plus State Agencies
And Institutions
Operation Of An Approved MMIS: Cost of
Private Sector Contractors
Mechanized Systems, Not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Form CMS 64.10I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Administration
Special Issue Reporting Program
Total
Computable
(A)
7A
7B
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Federal Share
FPP
Federal Other % Federal
Rate
Share
Share
(B)
(C)
Total
Federal
Share
(D)
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Nurse Aide Training Costs
Preadmission Screening Costs
Resident Review Activities Costs
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary 90%
TANF Secondary 75%
External Review
Enrollment Brokers
School Based Administration
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs
Translation and Interpretation
Health Information Technology
Administration
Form CMS 64.10I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Administration
Special Issue Reporting Program
Total
Computable
(A)
Federal Share
FPP
Federal Other % Federal
Rate
Share
Share
(B)
(C)
Total
Federal
Share
(D)
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
29 Other Financial Participation
30 Total
Form CMS 64.10I
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program
Total
Computable
FFP
Rate
(A)
1
2A
2B
3A
3B
4A
4B
5A
5B
Deferral or
CIN Number
Federal Share
Federal
Federal
Share Other % Share
(B)
(C)
Total
Federal
Share
(D)
(E)
Family Planning
Design Development Or Installation Of
MMIS: Costs Of In-House Activities
Design Development Or Installation Of
MMIS: Costs Of Private Sector Contractors
Skilled Professional Medical PersonnelSingle State Agency
Skilled Professional Medical Personnel Other Agency
Operation Of An Approved MMIS: Cost Of
In-House Activities
Operation Of An Approved MMIS: Cost Of
Private Sector Contractors
Mechanized Systems, not Approved Under
MMIS Procedures: Costs Of In-House
Activities
Mechanized Systems, Not Approved Under
MMIS Procedures: Cost Of Private Sector
Contractors
Form CMS 64.10PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program
Total
Computable
FFP
Rate
(A)
5C
6
7A
7B
8
9
10
11
12
13
14
15
16
17
18
19
Deferral or
CIN Number
Federal Share
Federal
Federal
Share Other % Share
(B)
(C)
Total
Federal
Share
(D)
(E)
Mechanized Systems - Not Approved under
MMIS Procedures: Interagency
Quality Improvement Organizations
Third Party Liability: Recovery Procedure Billing Offset
Third Party Liability: Assignment Of Rights Billing Offset
Immigration Status Verification System
Costs (100% FFP)
Nurse Aide Training
Preadmission Screening Costs
Resident Review Activities Cost
Drug Use Review Program
Outstationed Eligibility Workers
TANF Base
TANF Secondary (90%)
TANF Secondary (75%)
External Review
Enrollment Brokers
School Based Administration
Form CMS 64.10PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended: 12/31/2010
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program
Total
Computable
FFP
Rate
(A)
20
21
22
23
24
Deferral or
CIN Number
Federal Share
Federal
Federal
Share Other % Share
(B)
(C)
Total
Federal
Share
(D)
(E)
Program Integrity/Fraud, Waste, and Abuse
Activities
County/Local ADM Costs
Interagency Costs
Translation and Interpretation
Health Information Technology
Administration
24A HIT: Planning: Cost of In-house Activities
24B HIT: Planning: Cost of Private Contractors
HIT: Implementation and Operation: Cost of
24C In-house Activities
HIT: Implementation and Operation: Cost of
24D Private Contractors
Citizenship Verification Technology 25 CHIPRA
25A CVT Development - CHIPRA
25B CVT Operation - CHIPRA
29 Other Financial Participation
30 Total
Form CMS 64.10PI
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
6b
7
Federal Share
Medicaid
Medicaid
and CHIP
FMAP
Enhanced
Increased
FMAP Rate FMAP Rate
(B)
(C)
Applied
against the
20% Limit
CHIP
Amount
(D)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Form CMS 64.9T
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
Federal Share
Medicaid
Medicaid
and CHIP
FMAP
Enhanced
Increased
FMAP Rate FMAP Rate
(B)
(C)
Applied
against the
20% Limit
CHIP
Amount
(D)
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services - Supplemental
9B Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions No.
15 EPSDT Screening Services
16 Rural Health Clinic Screening
Medicare Health Insurance Payments - Part
17A A Premiums
Medicare Health Insurance Payments - Part
17B B Premiums
17C1120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
Form CMS 64.9T
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Total
Computable
(A)
22
Federal Share
Medicaid
Medicaid
and CHIP
FMAP
Enhanced
Increased
FMAP Rate FMAP Rate
(B)
(C)
Applied
against the
20% Limit
CHIP
Amount
(D)
Programs Of All-Inclusive Care Elderly
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
32
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
35
36
37
38
39
Diagnostic Screening & Preventive Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
40
41
42
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
27
28
29
30
31
43
44
49
50
Form CMS 64.9T
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
6b
7
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Form CMS 64.9TP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services 9B Supplemental Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions No.
15 EPSDT Screening Services
16 Rural Health Clinic Screening
Medicare Health Insurance Payments 17A Part A Premiums
Medicare Health Insurance Payments 17B Part B Premiums
17C1120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
Form CMS 64.9TP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
22
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
Programs Of All-Inclusive Care Elderly
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
49
50
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9TP
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
6b
7
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Form CMS 64.9TP WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services 9B Supplemental Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions No.
15 EPSDT Screening Services
16 Rural Health Clinic Screening
Medicare Health Insurance Payments 17A Part A Premiums
Medicare Health Insurance Payments 17B Part B Premiums
17C1120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
22 Programs Of All-Inclusive Care Elderly
Form CMS 64.9TP WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Prior Period Adjustments in This Quarter
State:
Quarter Ended: 12/31/2010
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
Federal Share
Deferral or
CIN
Number
(A)
Applied
against
Medicaid
Medicaid the 20%
and CHIP
FMAP
Limit
Enhanced Increased
CHIP
FMAP Rate FMAP Rate Amount
(B)
(C)
(D)
(E)
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
49
50
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive
Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9TP WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
1B
1C
1D
2A
2B
3A
3B
4A
4B
4C
5A
5A
6A
6b
7
Total
Computable
Federal Share
(A)
Applied
Medicaid
Medicaid against the
and CHIP
FMAP
20% Limit
Enhanced
Increased
CHIP
FMAP Rate FMAP Rate
Amount
(B)
(C)
(D)
Inpatient Hospital Services - Regular
Payments
Inpatient Hospital Service - DSH
Adjustment Payments
Inpatient Hospital Services - Supplemental
Payments
Inpatient Hospital Services - GME
Payments
Mental Health Facility Services - Regular
Payments
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Regular
Payments
Nursing Facility Services - Supplemental
Payments
Intermediate Care Facility Services Mentally Retarded: Public Providers
Intermediate Care Facility Services Mentally Retarded: Private Providers
Intermediate Care Facility Services Supplemental Payments
Physician and Surgical Services - Regular
Payments
Physician and Surgical Services Supplemental Payments
Outpatient Hospital Services - Regular
Payments
Outpatient Hospital Services Supplemental Payments
Prescribed Drugs
7A1 Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
7A2 Agreement
7A3 MCO - National Agreement
7A4 MCO - State Sidebar Agreement
Form CMS 64.9T WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Total
Computable
Federal Share
(A)
Applied
Medicaid
Medicaid against the
and CHIP
FMAP
20% Limit
Enhanced
Increased
CHIP
FMAP Rate FMAP Rate
Amount
(B)
(C)
(D)
Increased ACA OFFSET - Fee for Service 7A5 100%
7A6 Increased ACA OFFSET - MCO - 100%
8
Dental Services
Other Practitioners Services - Regular
9A Payments
Other Practitioners Services - Supplemental
9B Payments
10 Clinic Services
11 Laboratory And Radiological Services
12 Home Health Services
13 Sterilizations
14 Abortions No.
15 EPSDT Screening Services
16 Rural Health Clinic Screening
Medicare Health Insurance Payments - Part
17A A Premiums
Medicare Health Insurance Payments - Part
17B B Premiums
17C1120% - 134% Of Poverty
17D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18A Managed Care Organizations (MCO)
18B1Prepaid Ambulatory Health Plan
18B2Prepaid Inpatient Health Plan
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Medicaid Health Insurance Payments:
18D Coinsurance And Deductibles
Medicaid Health Insurance Payments:
18E Other
Home and Community-Based Services 19A Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
Form CMS 64.9T WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
22
Total
Computable
Federal Share
(A)
Applied
Medicaid
Medicaid against the
and CHIP
FMAP
20% Limit
Enhanced
Increased
CHIP
FMAP Rate FMAP Rate
Amount
(B)
(C)
(D)
Programs Of All-Inclusive Care Elderly
23A Personal Care Services - Regular Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
25
26
32
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and
Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
35
36
37
38
39
Diagnostic Screening & Preventive Services
Nurse Mid-Wife
Emergency Hospital Services
Critical Access Hospitals
Nurse Practitioner Services
School Based Services
40
41
42
Rehabilitative Services (non-school-based)
Private Duty Nursing
Freestanding Birth Center
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
27
28
29
30
31
43
44
49
50
Form CMS 64.9T WAIVER
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 8/31/2011
Fraud, Waste & Abuse Amounts Credited
From Medicaid Program Integrity Activities
State:
Quarter Ended: 12/31/2010
Medical Assistance Payments
1
1A
1B
1C
2
3
4
5
6
50
Medicaid ARRA
Total
Federal Federal Federal
Computable
Share
Share
Share
(A)
(B)
(C)
(D)
Amounts Identified from State PI activities
Data mining activities
PI Provider audits
Other
MFCU Investigations
Settlements/Judgments
Civil Monetary Penalties
CMS Medicaid Integrity Contractors (MICs)
Other
Total
* This sheet will calculate the bottom line totals for Total Computable and Federal Share to generate the figures for Line
9C1, Columns A, B, C and D (Medical Assistance Payments) of the CMS-64 Summary Sheet.
Form CMS 64.9C1
Report Date: Friday, November 12, 2010 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
RECOVERIES FROM OIG STATE COMPLIANT FCA
State:
Quarter Ended: 12/31/2010
Total
Computable
Medical Assistance Payments
(A)
1
Recoveries from OIG Certified Compliant FCA
1A Total Recovery
Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
1B approved State law
10% Reduction FMAP Rate (to be used in the grant award
2
computation)
OMB No. 0938-0067
Expires 8/31/2011
FMAP
Rate
Federal
Share
(B)
* These recovery amounts should not be included in any recovery amounts reported on the Fraud, Waste and Abuse
* Recoveries from the State Medicaid Program Integrity Activities Form.
Form CMS 64.9C2
Report Date: Friday, November 12, 2010 - 12:00 AM
| File Type | application/pdf |
| Author | dmast |
| File Modified | 2010-11-16 |
| File Created | 2010-11-15 |