CMS-10398-10 1115 Demonstration Application Budget Neutrality Table S

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

Interim Section 1115 Demonstration Application BN Table Shell v2.xlsx

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

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Overview

Historic Data
WOW
WW
DSH
Summary
Dropdown

Sheet 1: Historic Data

5 YEARS OF HISTORIC DATA

SPECIFY TIME PERIOD AND ELIGIBILITY GROUP DEPICTED:

Medicaid Pop 1	HY 1	HY 2	HY 3	HY 4	HY 5	5-YEARS
TOTAL EXPENDITURES						$-
ELIGIBLE MEMBER MONTHS
PMPM COST	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
TREND RATES						5-YEAR
			ANNUAL CHANGE			AVERAGE
TOTAL EXPENDITURE		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
ELIGIBLE MEMBER MONTHS		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM COST		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 2	HY 1	HY 2	HY 3	HY 4	HY 5	5-YEARS
TOTAL EXPENDITURES						$-
ELIGIBLE MEMBER MONTHS
PMPM COST	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
TREND RATES						5-YEAR
			ANNUAL CHANGE			AVERAGE
TOTAL EXPENDITURE		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
ELIGIBLE MEMBER MONTHS		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM COST		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 3	HY 1	HY 2	HY 3	HY 4	HY 5	5-YEARS
TOTAL EXPENDITURES						$-
ELIGIBLE MEMBER MONTHS
PMPM COST	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
TREND RATES						5-YEAR
			ANNUAL CHANGE			AVERAGE
TOTAL EXPENDITURE		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
ELIGIBLE MEMBER MONTHS		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM COST		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Other Data	HY 1	HY 2	HY 3	HY 4	HY 5	5-YEARS
TOTAL EXPENDITURES						$-
ELIGIBLE MEMBER MONTHS
PMPM COST	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
TREND RATES						5-YEAR
			ANNUAL CHANGE			AVERAGE
TOTAL EXPENDITURE		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
ELIGIBLE MEMBER MONTHS		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM COST		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Sheet 2: WOW

DEMONSTRATION WITHOUT WAIVER (WOW) BUDGET PROJECTION: COVERAGE COSTS FOR POPULATIONS


ELIGIBILITY	TREND	MONTHS	BASE YEAR	TREND	DEMONSTRATION YEARS (DY)					TOTAL
GROUP	RATE 1	OF AGING	DY 00	RATE 2	DY 01	DY 02	DY 03	DY 04	DY 05	WOW

Medicaid Pop 1
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!	0	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure					#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 2
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!	0	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!	0	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure					#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 3
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!	0	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!	0	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure					#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Sheet 3: WW

DEMONSTRATION WITH WAIVER (WW) BUDGET PROJECTION: COVERAGE COSTS FOR POPULATIONS


			DEMONSTRATION YEARS (DY)					TOTAL WW
ELIGIBILITY GROUP	DY 00	DEMO TREND RATE	DY 01	DY 02	DY 03	DY 04	DY 05

Medicaid Pop 1
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure			#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 2
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure			#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Medicaid Pop 3
Pop Type:	Medicaid
Eligible Member Months	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
PMPM Cost	#DIV/0!		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Total Expenditure			#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Exp Pop 1
Pop Type:	Expansion
Eligible Member Months
PMPM Cost
Total Expenditure			$-	$-	$-	$-	$-	$-

Exp Pop 2
Pop Type:	Expansion
Eligible Member Months
PMPM Cost
Total Expenditure			$-	$-	$-	$-	$-	$-

Sheet 4: DSH

Panel 1: Historic DSH Claims for the Last Five Fiscal Years:
RECENT PAST FEDERAL FISCAL YEARS
	20__	20__	20__	20__	20__
State DSH Allotment (Federal share)
State DSH Claim Amount (Federal share)
DSH Allotment Left Unspent (Federal share)	$-	$-	$-	$-	$-

Panel 2: Projected Without Waiver DSH Expenditures for FFYs That Overlap the Demonstration Period
FEDERAL FISCAL YEARS THAT OVERLAP DEMONSTRATION YEARS
	FFY 00 (20__)	FFY 01 (20__)	FFY 02 (20__)	FFY 03 (20__)	FFY 04 (20__)	FFY 05 (20__)
State DSH Allotment (Federal share)
State DSH Claim Amount (Federal share)
DSH Allotment Projected to be Unused (Federal share)	$-	$-	$-	$-	$-	$-

Panel 3: Projected With Waiver DSH Expenditures for FFYs That Overlap the Demonstration Period
FEDERAL FISCAL YEARS THAT OVERLAP DEMONSTRATION YEARS
	FFY 00 (20__)	FFY 01 (20__)	FFY 02 (20__)	FFY 03 (20__)	FFY 04 (20__)	FFY 05 (20__)
State DSH Allotment (Federal share)	$-	$-	$-	$-	$-	$-
State DSH Claim Amount (Federal share)
Maximum DSH Allotment Available for Diversion (Federal share)
Total DSH Alltoment Diverted (Federal share)	$-	$-	$-	$-	$-	$-
DSH Allotment Available for DSH Diversion Less Amount Diverted (Federal share, must be non-negative)	$-	$-	$-	$-	$-	$-
DSH Allotment Projected to be Unused (Federal share, must be non-negative)	$-	$-	$-	$-	$-	$-

Panel 4: Projected DSH Diversion Allocated to DYs
DEMONSTRATION YEARS
		DY 01	DY 02	DY 03	DY 04	DY 05
DSH Diversion to Leading FFY (total computable)
FMAP for Leading FFY

DSH Diversion to Trailing FFY (total computable)
FMAP for Trailing FFY

Total Demo Spending From Diverted DSH (total computable)		$-	$-	$-	$-	$-

Sheet 5: Summary

Budget Neutrality Summary

Without-Waiver Total Expenditures
	DEMONSTRATION YEARS (DY)					TOTAL
	DY 01	DY 02	DY 03	DY 04	DY 05
Medicaid Populations
Medicaid Pop 1	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Medicaid Pop 2	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Medicaid Pop 3	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!



TOTAL	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

With-Waiver Total Expenditures
	DEMONSTRATION YEARS (DY)					TOTAL
	DY 01	DY 02	DY 03	DY 04	DY 05
Medicaid Populations
Medicaid Pop 1	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Medicaid Pop 2	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!
Medicaid Pop 3	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Expansion Populations
Exp Pop 1	$-	$-	$-	$-	$-	$-
Exp Pop 2	$-	$-	$-	$-	$-	$-


TOTAL	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

VARIANCE	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

Sheet 6: Dropdown

Population Status Drop-Down

Medicaid

Expansion

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File Modified	0000-00-00
File Created	0000-00-00