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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medicaid Assistance Expenditures
For the Medical Assistance Program
State:
Quarter Ended: 03/31/2013
Certification
Medical Assistance Payments
CMS 64 Summary Sheet
State and Local Administration
Total
Federal Share
Total
Federal Share
(A)
(B)
(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 officer 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
indicated above.
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, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance
Program Summary Sheet
Total
Computable
(A)
Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)
Quarter Ended:
State and Local
Administration
Total
(E)
Total Computable Federal Share
(F)
(G)
Section A. Quarterly Status of Funding
1
Awards Received During The Quarter For The Quarter Being
Reported And Prior Quarters
2
Awards Received During The Quarter For Subsequent Quarters
3A
Interest: Received On Medicaid Recoveries
3B
Interest: Assessed On Disallowances
4
Medicare Overpayment Collection Under Sec. 1914 and 42 CFR
447.30
5
Other
Section B. Expenditures Reported for Period
6
Expenditures In This Quarter
7
Adjustments Increasing Claims For Prior Quarters
8
Other Expenditures
9A
Collections: Third Party Liability
9B
Collections: Probate
9C1
Recoveries: Fraud, Waste and Abuse Efforts
9C2
Recoveries: OIG Compliant False Claims Act
9D
Collections: Other
9E
RAC Collections
9F
PERM Collections
Form CMS 64 Summary
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance
Program Summary Sheet
Total
Computable
(A)
10A
Adjustments Decreasing Claims For Prior Quarters: Federal Audit
10B
Adjustments Decreasing Claims For Prior Quarters: Other
10C
Adjustments Decreasing Claims For Prior Quarters: Overpayment
Adjustments (Attach 64.9O)
10D
Adjustments/Decreasing Prior Qtrs - Perm
10E
Adjustments/Decreasing Prior Qtrs - RAC
10F
Adjustments/Decreasing Prior Qtrs - Fraud, Waste and Abuse
Overpayments
11
Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)
Quarter Ended:
State and Local
Administration
Total
(E)
Total Computable Federal Share
(F)
(G)
Net Expenditures Reported In This Period (Sum of Items 6, 7 and 8
Less 9 and 10)
Form CMS 64 Summary
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Total
Comp.
FMAP
(A)
(B)
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9Base
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(C)
(D)
(E)
(F)
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(B)
Federal Share
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
(A)
Prompt Pay
(PP)
Total
Federal
Share
Clinic Services
17A
17C1
FMAP
Dental Services
Other Practitioners Services - Regular
Payments
11
Total
Comp.
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9A
10
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9Base
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
18B1
c
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9Base
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9Base
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Quarter Ended:
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9 Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
FMAP
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
Total
Comp.
Other %
(Oth)
Clinic Services
17A
17C1
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Dental Services
Other Practitioners Services - Regular
Payments
11
Federal Share
Increased ACA OFFSET - MCO - 100%
9A
10
Quarter Ended:
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9 Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
18B1
c
Quarter Ended:
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9 Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Quarter Ended:
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
Other & Prompt Pay
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(C)
(D)
(E)
(F)
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Nursing Facility Services - Regular Payments
3B
5D
(A)
Prompt Pay
(PP)
Total
Federal
Share
Inpatient Hospital Services - GME Payments
2A
3A
FMAP
Other %
(Oth)
Inpatient Hospital Services: Regular Payments
1B
1D
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
Other & Prompt Pay
7A4
7A5
7A6
8
14
15
16
(F)
(G)
(H)
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(E)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(D)
Clinic Services
17A
18A1
(C)
Dental Services
Other Practitioners Services - Supplemental
Payments
13
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Increased ACA OFFSET - MCO - 100%
9B
12
(A)
Prompt Pay
(PP)
Total
Federal
Share
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
FMAP
Other %
(Oth)
MCO - State Sidebar Agreement
9A
10
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
Other & Prompt Pay
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(C)
(D)
(E)
(F)
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
MCO PAHP - Evaluation and Management
18D
23A
(A)
Prompt Pay
(PP)
Total
Federal
Share
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
FMAP
Other %
(Oth)
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
Other & Prompt Pay
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
Other & Prompt Pay
43
44
49
50
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
FMAP
Other %
(Oth)
Nursing Facility Services - Regular Payments
3B
5D
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Inpatient Hospital Services - GME Payments
2A
3A
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Inpatient Hospital Services: Regular Payments
1B
1D
Federal Share
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9P Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
7A4
7A5
7A6
8
14
15
16
(D)
(E)
(F)
(G)
(H)
Home Health
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Clinic Services
17A
18A1
(A)
Prompt Pay
(PP)
Total
Federal
Share
Dental Services
Other Practitioners Services - Supplemental
Payments
13
FMAP
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9B
12
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
MCO - State Sidebar Agreement
9A
10
Federal Share
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9P Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
FMAP
Other %
(Oth)
MCO PAHP - Evaluation and Management
18D
23A
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Federal Share
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9P Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9P Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
43
44
49
50
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9P Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medicaid Overpayment Adjustment
State:
Quarter Ended:
Total
Federal Share
Computable
Overpayment Activity
1 Overpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Year Time
Limit
(A)
ARRA:
Total
FY
FY
FY
FY
(B)
(C)
(D)
(E)
ARRA:
BIPP:
BIPP:
Federal
(F)
ARRA:
BIPP:
2 Decreasing Adjustments To
Amounts Previously Reported On
Line 1
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
3 Subtotal
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
4 Previously Reported Overpayments
To Providers Certified This Quarter
As Bankrupt Or Out Of Business
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
5 Total Overpayment Adjustments
This Quarter
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
Form CMS 64.9O
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Fraud, Waste & Abuse Amounts Overpayments - Federal Credit Due
From Medicaid Program Integrity Activities
State:
Medical Assistance Payments
Total
Computable
Medicaid
Federal Share
ARRA Federal
Share
BIPP Federal
Share
Federal Share
(A)
(B)
(C)
(D)
(E)
1. Amounts Identified from State PI activities
1A. Data mining activities
1B. PI Provider audits
1C. Other
2. MFCU Investigations
3. Settlements/Judgements
4. Civil Monetary Penalties
5. CMS Medicaid Integrity Contractors (MICs)
6. Other
7. Sub-Total
8. Decreasing Adjustments to Amounts Previously Reported on Line 7
9. Decreasing Adjustments - Amounts Previously Reported Overpayments to
Providers Certified this Quarter as Bankrupt or Out of Business
10. Total
Form CMS 64.9OFWA
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medicaid Overpayment Adjustment
State:
Quarter Ended:
Federal Share
Total
Computable
PERM Activity
1 Overpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Year Time
Limit
Total
PERM-identified Overpayments
(A)
ARRA:
FY
FY
FY
FY
(B)
(C)
(D)
(E)
ARRA:
BIPP:
BIPP:
Federal
(F)
ARRA:
BIPP:
2 Decreasing Adjustments To
Amounts Previously Reported On
Line 1
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
3 Subtotal
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
4 Previously Reported Overpayments
To Providers Certified This Quarter
As Bankrupt Or Out Of Business
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
5 Total Overpayment Adjustments
This Quarter
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
Form CMS 64.9O PERM
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medicaid Overpayment Adjustment
State:
Quarter Ended:
Federal Share
Total
Computable
RAC Activity
1 Overpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Year Time
Limit
Total
RAC-identified Overpayments
(A)
ARRA:
FY
FY
FY
FY
(B)
(C)
(D)
(E)
ARRA:
BIPP:
BIPP:
Federal
(F)
ARRA:
BIPP:
2 Decreasing Adjustments To
Amounts Previously Reported On
Line 1
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
3 Subtotal
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
4 Previously Reported Overpayments
To Providers Certified This Quarter
As Bankrupt Or Out Of Business
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
5 Total Overpayment Adjustments
This Quarter
ARRA:
ARRA:
BIPP:
BIPP:
ARRA:
BIPP:
Form CMS 64.9O RAC
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Third Party Liability Collections And Cost Avoidance
Quarter Ended:
State:
Total Computable
Medicaid FS
ARRA FS
BIPP FS
Federal Share
(A)
(B)
(C)
(D)
(E)
A. Third Party Liability Collections
1.a.
Medicare Collections
b.1. Other Collection - Health Insurance
2. Other Collections - Casualty Insurance
c.
Total Collections - Cooperative Agreements & Assign of Rights
1. Less: Excess Paid to Individuals
2. Net Collections To Reimburse State Title XIX Medical Payments
3. Less 15% Incentive Actually Paid Under Section 1903(p)(1)
4. Net Federal Share
2.
Total TPL Collections
B. Cost Avoidance
1.
Medicare Title XVIII
2.
Health Insurance
3.
Other Cost Avoidance
Form CMS 64.9A
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share matched at 100%
Medical Assistance Payments
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Total
Comp.
FMAP
(A)
(B)
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share matched at 100%
Medical Assistance Payments
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(C)
(D)
(E)
(F)
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(B)
Federal Share
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
(A)
Prompt Pay
(PP)
Total
Federal
Share
Clinic Services
17A
17C1
FMAP
Dental Services
Other Practitioners Services - Regular
Payments
11
Total
Comp.
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9A
10
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share matched at 100%
Medical Assistance Payments
18B1
c
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share matched at 100%
Medical Assistance Payments
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share matched at 100%
Other & Prompt Pay
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(C)
(D)
(E)
(F)
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Nursing Facility Services - Regular Payments
3B
5D
(A)
Prompt Pay
(PP)
Total
Federal
Share
Inpatient Hospital Services - GME Payments
2A
3A
FMAP
Other %
(Oth)
Inpatient Hospital Services: Regular Payments
1B
1D
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share matched at 100%
Other & Prompt Pay
7A4
7A5
7A6
8
14
15
16
(F)
(G)
(H)
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(E)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(D)
Clinic Services
17A
18A1
(C)
Dental Services
Other Practitioners Services - Supplemental
Payments
13
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Increased ACA OFFSET - MCO - 100%
9B
12
(A)
Prompt Pay
(PP)
Total
Federal
Share
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
FMAP
Other %
(Oth)
MCO - State Sidebar Agreement
9A
10
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share matched at 100%
Other & Prompt Pay
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(C)
(D)
(E)
(F)
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
MCO PAHP - Evaluation and Management
18D
23A
(A)
Prompt Pay
(PP)
Total
Federal
Share
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
FMAP
Other %
(Oth)
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Optional
Breast or
Cerv.
Cancer
Services *
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share matched at 100%
Other & Prompt Pay
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share matched at 100%
Other & Prompt Pay
43
44
49
50
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
All columns matched at 100%, State Share applied to 200K
Form CMS 64.9 200K P
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
School Based Administration
Form CMS 64.10Base
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Total
Computable
(A)
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs (State Level)
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10Base
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
School Based Administration
Form CMS 64.10 Waiver
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Waiver Type:
Waiver Name:
Waiver Number:
Total
Computable
(A)
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10 Waiver
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs
Of In-House Activities
2B
Design Development Or Installation Of MMIS: Costs
Of Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private
Sector Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
Form CMS 64.10P
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
Form CMS 64.10P
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10P
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs
Of In-House Activities
2B
Design Development Or Installation Of MMIS: Costs
Of Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private
Sector Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
Form CMS 64.10P Waiver
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Federal Share
Total
Computable
(A)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
Form CMS 64.10P Waiver
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Waiver Type:
Waiver Name:
Waiver Number:
Federal Share
Total
Computable
(A)
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10P Waiver
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
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:
Plan Name
(A)
Quarter Ended:
Receipts
(B)
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
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Provider-Related Donations And
Health Care Related Taxes, Fees, And
Received Under Public Law 102-234
Actual Receipts By Plan Name
State:
CODE:
1. Donations - Medicaid
1.A. Donations - CHIP
2. Donations- Outstationed Eligibility Workers - Medicaid
2.A. Donations - Outstationed Eligibility Workers - CHIP
Code
(A)
Form CMS 64.11A
Plan Name
(B)
3. Taxes
4. Fees
5. Assessments
Receipts
(C)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended:
Inpatient Hospital
Mental Health Facility
Services
1115 DSH Diversion
Total
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
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
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
Form CMS 64.9D
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended:
Inpatient Hospital
Mental Health Facility
Services
1115 DSH Diversion
Total
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
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 2010 Allotment
11
Additional Increased FFY 2010 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 2010 Increased Allotment
16
Excess Expenditures
FFY 2011 (10/01/2010 - 09/30/2011)
1
FFY 2011 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 2011 Allotment
10
Excess Expenditures
Form CMS 64.9D
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Allocation of Disproportionate Share Hospital
Payment Adjustments to Applicable FFYs
State:
Quarter Ended:
Inpatient Hospital
Mental Health Facility
Services
1115 DSH Diversion
Total
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
Total
Computable
Federal Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
FFY 2012 (10/01/2011 - 09/30/2012)
1
FFY 2012 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 2012 Allotment
10
Excess Expenditures
FFY 2013 (10/01/2012 - 09/30/2013)
1
FFY 2013 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 2013 Allotment
10
Excess Expenditures
Form CMS 64.9D
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medicaid Drug Rebate Schedule
State:
Quarter Ended:
Total Computable
Drug Rebate
Qtr. Ending
Qtr. Ending Qtr. Ending Qtr. Ending
Qtr. Ending
03/31/2013
12/31/2012
09/30/2012
06/30/2012
03/31/2012
and Prior
(C)
(D)
(E)
(A)
1
Balance Of The Beginning Of The Quarter
2
Adjustments To Previously Reported Rebates From
Drug Labelers Included In Line 1
3
Rebates Invoiced In This Quarter
4
Subtotal
5
Rebates Reported On This Expenditure Report
6
Balance As Of The End Of The Quarter
(B)
Total
(F)
FOOTNOTE:
Form CMS 64.9R
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Medicaid Program Expenditure Report
Other Narrative Explainations
Quarter Ended:
Narrative
Form CMS 64 Narrative
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Federal Share
Type of Eligible:
Total
Computable
(A)
1A
Premiums: Up To 150% of Poverty Level - Gross
Premiums Paid
1B
Premiums Up To 150% of Poverty Level: Cost
Sharing Offsets
1C
Premiums Over 150% of Poverty Level - Gross
Premiums Paid
1D
Premiums Over 150% of Poverty Level: Cost
Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments
Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH
Adjustment Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
Form CMS 64.21
FMAP
**
(B)
IHS Facility
Services
100 %
(C)
Fam. Plan
Services
90%
(D)
Prompt Pay
Total
Federal
(E)
(F)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Federal Share
Type of Eligible:
Total
Computable
(A)
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular
Payment (WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21
FMAP
**
(B)
IHS Facility
Services
100 %
(C)
Fam. Plan
Services
90%
(D)
Prompt Pay
Total
Federal
(E)
(F)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Fiscal Year: /
Line #
Type of Eligible:
Federal Share
FMAP
Total
Computable
Incr. FMAP
(A)
(B)
**
1A
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offset
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offset
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
Form CMS 64.21P
I.H.S Facility
Services
100%
Fam. Plan
Services
90%
(C)
(D)
Prompt Pay
Total
Federal
Share
Deferral or
C.I.N.
Number
(E)
(F)
(G)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Fiscal Year: /
Line #
Type of Eligible:
Federal Share
FMAP
Total
Computable
Incr. FMAP
(A)
(B)
**
13
Therapy Services
14
Laboratory And Radiological services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21P
I.H.S Facility
Services
100%
Fam. Plan
Services
90%
(C)
(D)
Prompt Pay
Total
Federal
Share
Deferral or
C.I.N.
Number
(E)
(F)
(G)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
Quarter Ended:
Federal Share
Total
Computable
(A)
1A
Premiums: Up To 150% of Poverty Level - Gross
Premiums Paid
1B
Premiums Up To 150% of Poverty Level: Cost
Sharing Offsets
1C
Premiums Over 150% of Poverty Level - Gross
Premiums Paid
1D
Premiums Over 150% of Poverty Level: Cost
Sharing Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments
Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH
Adjustment Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
Form CMS 64.21 Waiver
FMAP
**
(B)
IHS Facility
Services
100 %
(C)
Fam. Plan
Services
90%
(D)
Prompt Pay
Total
Federal
(E)
(F)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
Quarter Ended:
Federal Share
Total
Computable
(A)
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular
Payment (WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21 Waiver
FMAP
**
(B)
IHS Facility
Services
100 %
(C)
Fam. Plan
Services
90%
(D)
Prompt Pay
Total
Federal
(E)
(F)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Fiscal Year: /
Line #
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offset
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offset
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH
Adjustments Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
Form CMS 64.21P Waiver
Federal Share
FMAP
Total
Computable
Incr. FMAP
(A)
(B)
**
I.H.S Facility
Services
100%
Fam. Plan
Services
90%
(C)
(D)
Prompt Pay
Total
Federal
Share
Deferral or
C.I.N.
Number
(E)
(F)
(G)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Fiscal Year: /
Line #
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
13
Therapy Services
14
Laboratory And Radiological services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21P Waiver
Federal Share
FMAP
Total
Computable
Incr. FMAP
(A)
(B)
**
I.H.S Facility
Services
100%
Fam. Plan
Services
90%
(C)
(D)
Prompt Pay
Total
Federal
Share
Deferral or
C.I.N.
Number
(E)
(F)
(G)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Type of Eligible:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment
Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
Form CMS 64.21U
Total
Computable
FMAP
(A)
(B)
Federal Share
Enhanced
FMAP
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Quarter Ended:
Type of Eligible:
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21U
Total
Computable
FMAP
(A)
(B)
Federal Share
Enhanced
FMAP
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustment
Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
13
Therapy Services
Form CMS 64.21U Waiver
Quarter Ended:
Total
Computable
FMAP
(A)
(B)
Federal Share
Enhanced
FMAP
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Total
Form CMS 64.21U Waiver
Quarter Ended:
Total
Computable
FMAP
(A)
(B)
Federal Share
Enhanced
FMAP
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
Form CMS 64.21UP
Federal Share
Enhanced
FMAP
Incr FMAP
FMAP
(B)
(C)
Total
Federal
Share
Deferral
or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Type of Eligible:
Total
Computable
(A)
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21UP
Federal Share
Enhanced
FMAP
Incr FMAP
FMAP
(B)
(C)
Total
Federal
Share
Deferral
or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
1A
Premiums Up To 150% Of Poverty Level - Gross Premiums
Paid
1B
Premiums Up To 150% Of Poverty Level - Cost Sharing
Offsets
1C
Premiums Over 150% Of Poverty Level - Gross Premiums
Paid
1D
Premiums Over 150% Of Poverty Level - Cost Sharing
Offsets
2
Inpatient Hospital Services - Regular Payments
2A
Inpatient Hospital Services - DSH Adjustments Payments
3
Inpatient Mental Health Facility Services - Regular
Payments
3A
Inpatient Mental Health Facility Services - DSH Adjustments
Payments
4
Nursing Care Services
5
Physician And Surgical Services
6
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
8A5
Increased ACA OFFSET - Fee for Service - 100%
8A6
Increased ACA OFFSET - MCO - 100%
9
Dental Services
10
Vision Services
11
Other Practitioners' Services
12
Clinic Services
Form CMS 64.21UP Waiver
Federal Share
Enhanced
FMAP
Incr FMAP
FMAP
Total
Computable
(A)
(B)
(C)
Total
Federal
Share
Deferral
or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
State:
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Type of Eligible:
Waiver Type:
Waiver Name:
Waiver Number:
13
Therapy Services
14
Laboratory And Radiological Services
15
Durable And Disposable Medical Equipment
16
Family Planning
17
Abortions
18
Screening Services
19
Home Health
20
Medicare Payments
21
Home And Community-Based Services
21A
Home and Community-Based Services - Regular Payment
(WAIVER)
22
Hospice
23
Medical Transportation
24
Case Management
25
Other Services
26
Balance
27
Collections
28
Total
Form CMS 64.21UP Waiver
Federal Share
Enhanced
FMAP
Incr FMAP
FMAP
Total
Computable
(A)
(B)
(C)
Total
Federal
Share
Deferral
or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Section C
Expenditures Reported for Period
By Form Number
Quarter Ended:
Medicaid Assist. Payments
State and Local Admin.
Medicaid/CHIP
Total Comp.
Fed. Share
Total Comp.
Fed. Share
20% Fed Shr
Total Comp.
(A)
(B)
(C)
(D)
(E)
(F)
Federal Share
(G)
6. Expenditures In This Quarter
From Form CMS-64.9/CMS-64.10
From Form CMS-64.9T
From Form CMS-64.9E/CMS-64.9PE
From Form CMS-64.21
From Form CMS-64.21U
7. Adjustments Increasing Claims For Prior Quarters:
From Form CMS 64.9P/CMS 64.10
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.21P
From Form CMS-64.21UP
8. Other Expenditures
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS-64.21P
From Form CMS-64.21UP
9. Collections
From Form CMS-64.9 Summary
10. Adjustments Decreasing Claims For Prior Quarters: A. Federal Audit
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS 64.21P
From Form CMS 64.21UP
10. Adjustments Decreasing Claims For Prior Quarters: B. Other
From Form CMS 64.9P/CMS 64.10P
From Form CMS-64.9TP
From Form CMS-64.9EP/CMS-64.9PEP
From Form CMS 64.21P
Form CMS 64 F
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Section C
Expenditures Reported for Period
By Form Number
Quarter Ended:
Medicaid Assist. Payments
State and Local Admin.
Medicaid/CHIP
Total Comp.
Fed. Share
Total Comp.
Fed. Share
20% Fed Shr
Total Comp.
(A)
(B)
(C)
(D)
(E)
(F)
Federal Share
(G)
From Form CMS 64.21UP
10. Adjustments Decreasing Claims For Prior Quarters: C. State and MIC Overpayment Adjustments
From Form CMS-64.9O/64.9O ARRA
10. Adjustments Decreasing Claims For Prior Quarters: D. PERM-Identified Overpayments
From Form CMS-64.9OPerm
10. Adjustments Decreasing Claims For Prior Quarters: E. RAC-Identified Overpayments
From Form CMS-64.9ORAC
10. Adjustments Decreasing Claims For Prior Quarters: F. Fraud, Waste, and Abuse Overpayments
From Form CMS-64.9OFWA
11. Net Expenditures Reported In This Period:
Net Expenditures Reported This Period
Form CMS 64 F
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Optional
Total
Comp.
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9I
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(D)
(E)
(F)
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
(B)
Federal Share
Total
Federal
Share
Clinic Services
17A
17C1
(A)
Other %
(Oth)
Dental Services
Other Practitioners Services - Regular
Payments
11
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Increased ACA OFFSET - MCO - 100%
9A
10
Optional
Total
Comp.
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9I
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
18B1
c
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9I
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9I
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(C)
(D)
(E)
(F)
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
(B)
Deferral
Or
C.I.N.
Number
Nursing Facility Services - Regular Payments
3B
5D
(A)
Federal
Share
Total
Federal
Share
Inpatient Hospital Services - GME Payments
2A
3A
Incr FMAP
Other %
(Oth)
Inpatient Hospital Services: Regular Payments
1B
1D
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9PI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
7A4
7A5
7A6
8
14
15
16
(F)
(G)
(H)
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(E)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(D)
Clinic Services
17A
18A1
(C)
Dental Services
Other Practitioners Services - Supplemental
Payments
13
(B)
Deferral
Or
C.I.N.
Number
Increased ACA OFFSET - MCO - 100%
9B
12
(A)
Federal
Share
Total
Federal
Share
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Incr FMAP
Other %
(Oth)
MCO - State Sidebar Agreement
9A
10
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9PI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(C)
(D)
(E)
(F)
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
(B)
Deferral
Or
C.I.N.
Number
MCO PAHP - Evaluation and Management
18D
23A
(A)
Federal
Share
Total
Federal
Share
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Incr FMAP
Other %
(Oth)
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9PI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9PI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
43
44
49
50
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9PI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Administration
Special Issue Reporting Program:
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
School Based Administration
Form CMS 64.10I
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Administration
Special Issue Reporting Program:
Total
Computable
(A)
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10I
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program:
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs
Of In-House Activities
2B
Design Development Or Installation Of MMIS: Costs
Of Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private
Sector Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
Form CMS 64.10PI
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program:
Federal Share
Total
Computable
(A)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
Form CMS 64.10PI
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Administration
Special Issue Reporting Program:
Federal Share
Total
Computable
(A)
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10PI
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Medicaid and CHIP Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total Computable
(A)
1A
Inpatient Hospital Services - Regular Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental Payments
1D
Inpatient Hospital Services - GME Payments
2A
Mental Health Facility Services - Regular Payments
2B
Mental Health Facility Services - DSH Adjustment
Payments
3A
Nursing Facility Services - Regular Payments
3B
Nursing Facility Services - Supplemental Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Supplemental
Payments
5A
Physician and Surgical Services - Regular Payments
5B
Physician and Surgical Services - Supplemental
Payments
5C
Physician & Surgical Services - Evaluation and
Management
5D
Physician & Surgical Services - Vaccine codes
6A
Outpatient Hospital Services - Regular Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar Agreement
7A3
MCO - National Agreement
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service - 100%
Form CMS 64.9T
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Medicaid and CHIP Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total Computable
(A)
7A6
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners Services - Regular Payments
9B
Other Practitioners Services - 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
17A
Medicare Health Insurance Payments - Part A
Premiums
17B
Medicare Health Insurance Payments - Part B
Premiums
17C1
120% - 134% Of Poverty
17D
Coinsurance And Deductibles
18A
Medicaid Health Insurance Payments: Managed Care
Organizations (MCO)
18A1
Medicaid MCO - Evaluation and Management
18A2
Medicaid MCO - Vaccine codes
18A3
Medicaid MCO - Community First Choice
18A4
Medicaid MCO - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1
Prepaid Ambulatory Health Plan
18B1
a
MCO PAHP - Evaluation and Management
18B1
b
MCO PAHP - Vaccine codes
Form CMS 64.9T
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Medicaid and CHIP Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total Computable
(A)
18B1
c
MCO PAHP - Community First Choice
18B1
d
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2
Prepaid Inpatient Health Plan
18B2
a
MCO PIHP - Evaluation and Management
18B2
b
MCO PIHP - Vaccine codes
18B2
c
MCO PIHP - Community First Choice
18B2
d
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18C
Medicaid Health Insurance Payments: Group Health
Plan Payments
18D
Medicaid Health Insurance Payments: Coinsurance
And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services - Regular
Payment (Waiver)
19B
Home and Community-Based Services - State Plan
1915(i) Only Payment
19C
Home and Community-Based Services - State Plan
1915(j) Only Payment
19D
Home and Community Based Services State Plan
1915(k) Community First Choice
22
Programs Of All-Inclusive Care Elderly
23A
Personal Care Services - Regular Payment
23B
Personal Care Services - SDS 1915(j)
24A
Targeted Case Management Services - Community
Case-Management
24B
Case Management - State Wide
25
Primary Care Case Management Services
26
Hospice Benefits
27
Emergency Services for Undocumented Aliens
Form CMS 64.9T
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Medicaid and CHIP Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total Computable
(A)
28
Federally-Qualified Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
32
Services for Speech, Hearing and Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
Diagnostic Screening & Preventive Services
34A
Preventive Services Grade A OR B, ACIP Vaccines
and their Admin
35
Nurse Mid-Wife
36
Emergency Hospital Services
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Total
Form CMS 64.9T
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Medicaid and CHIP
Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Inpatient Hospital Services - GME Payments
2A
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar
Agreement
7A3
MCO - National Agreement
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9TP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Medicaid and CHIP
Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
7A6
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners Services - Regular
Payments
9B
Other Practitioners Services - 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
17A
Medicare Health Insurance Payments - Part
A Premiums
17B
Medicare Health Insurance Payments - Part
B Premiums
17C1
120% - 134% Of Poverty
17D
Coinsurance And Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18A1
Medicaid MCO - Evaluation and Management
18A2
Medicaid MCO - Vaccine codes
18A3
Medicaid MCO - Community First Choice
18A4
Medicaid MCO - Preventive Services Grade
A OR B, ACIP Vaccines and their Admin
18B1
Prepaid Ambulatory Health Plan
18B1
a
MCO PAHP - Evaluation and Management
Form CMS 64.9TP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Medicaid and CHIP
Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
18B1
b
MCO PAHP - Vaccine codes
18B1
c
MCO PAHP - Community First Choice
18B1
d
MCO PAHP - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18B2
Prepaid Inpatient Health Plan
18B2
a
MCO PIHP - Evaluation and Management
18B2
b
MCO PIHP - Vaccine codes
18B2
c
MCO PIHP - Community First Choice
18B2
d
MCO PIHP - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
Medicaid Health Insurance Payments: Group
Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
Programs Of All-Inclusive Care Elderly
23A
Personal Care Services - Regular Payment
23B
Personal Care Services - SDS 1915(j)
24A
Targeted Case Management Services Community Case-Management
24B
Case Management - State Wide
25
Primary Care Case Management Services
26
Hospice Benefits
Form CMS 64.9TP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Medicaid and CHIP
Medicaid FMAP
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
27
Emergency Services for Undocumented
Aliens
28
Federally-Qualified Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
32
Services for Speech, Hearing and Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
Diagnostic Screening & Preventive Services
34A
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
35
Nurse Mid-Wife
36
Emergency Hospital Services
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic
Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Total
Form CMS 64.9TP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Inpatient Hospital Services - GME Payments
2A
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar
Agreement
7A3
MCO - National Agreement
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9TP Waiver
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
1A
Medicaid FMAP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners Services - Regular
Payments
9B
Other Practitioners Services - 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
17A
Medicare Health Insurance Payments - Part
A Premiums
17B
Medicare Health Insurance Payments - Part
B Premiums
17C1
120% - 134% Of Poverty
17D
Coinsurance And Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
18A1
Medicaid MCO - Evaluation and Management
18A2
Medicaid MCO - Vaccine codes
18A3
Medicaid MCO - Community First Choice
18A4
Medicaid MCO - Preventive Services Grade
A OR B, ACIP Vaccines and their Admin
18B1
Prepaid Ambulatory Health Plan
18B1
a
MCO PAHP - Evaluation and Management
Form CMS 64.9TP Waiver
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
7A6
Medicaid FMAP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP
MCO PAHP - Vaccine codes
18B1
c
MCO PAHP - Community First Choice
18B1
d
MCO PAHP - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18B2
Prepaid Inpatient Health Plan
18B2
a
MCO PIHP - Evaluation and Management
18B2
b
MCO PIHP - Vaccine codes
18B2
c
MCO PIHP - Community First Choice
18B2
d
MCO PIHP - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
Medicaid Health Insurance Payments: Group
Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
Programs Of All-Inclusive Care Elderly
23A
Personal Care Services - Regular Payment
23B
Personal Care Services - SDS 1915(j)
24A
Targeted Case Management Services Community Case-Management
24B
Case Management - State Wide
25
Primary Care Case Management Services
26
Hospice Benefits
Form CMS 64.9TP Waiver
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
18B1
b
Medicaid FMAP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:
State:
Line #
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP
Emergency Services for Undocumented
Aliens
28
Federally-Qualified Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
32
Services for Speech, Hearing and Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
Diagnostic Screening & Preventive Services
34A
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
35
Nurse Mid-Wife
36
Emergency Hospital Services
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic
Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Total
Form CMS 64.9TP Waiver
Applied Against
the 20% Limit
FMAP
Total
Computable
(A)
27
Medicaid FMAP
Enhanced FMAP
(B)
Incr. FMAP
(C)
CHIP Amount
Deferral or
C.I.N. Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP Medicaid FMAP
FMAP
Total Computable
(A)
1A
Inpatient Hospital Services - Regular Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental Payments
1D
Inpatient Hospital Services - GME Payments
2A
Mental Health Facility Services - Regular Payments
2B
Mental Health Facility Services - DSH Adjustment
Payments
3A
Nursing Facility Services - Regular Payments
3B
Nursing Facility Services - Supplemental Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Supplemental
Payments
5A
Physician and Surgical Services - Regular Payments
5B
Physician and Surgical Services - Supplemental
Payments
5C
Physician & Surgical Services - Evaluation and
Management
5D
Physician & Surgical Services - Vaccine codes
6A
Outpatient Hospital Services - Regular Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7
Prescribed Drugs
7A1
Drug Rebate Offset - National Agreement
7A2
Drug Rebate Offset - State Sidebar Agreement
7A3
MCO - National Agreement
7A4
MCO - State Sidebar Agreement
7A5
Increased ACA OFFSET - Fee for Service - 100%
Form CMS 64.9T Waiver
Applied Against
the 20% Limit
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP Medicaid FMAP
FMAP
Total Computable
(A)
7A6
Increased ACA OFFSET - MCO - 100%
8
Dental Services
9A
Other Practitioners Services - Regular Payments
9B
Other Practitioners Services - 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
17A
Medicare Health Insurance Payments - Part A
Premiums
17B
Medicare Health Insurance Payments - Part B
Premiums
17C1
120% - 134% Of Poverty
17D
Coinsurance And Deductibles
18A
Medicaid Health Insurance Payments: Managed Care
Organizations (MCO)
18A1
Medicaid MCO - Evaluation and Management
18A2
Medicaid MCO - Vaccine codes
18A3
Medicaid MCO - Community First Choice
18A4
Medicaid MCO - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B1
Prepaid Ambulatory Health Plan
18B1
a
MCO PAHP - Evaluation and Management
18B1
b
MCO PAHP - Vaccine codes
Form CMS 64.9T Waiver
Applied Against
the 20% Limit
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP Medicaid FMAP
FMAP
Total Computable
(A)
18B1
c
MCO PAHP - Community First Choice
18B1
d
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18B2
Prepaid Inpatient Health Plan
18B2
a
MCO PIHP - Evaluation and Management
18B2
b
MCO PIHP - Vaccine codes
18B2
c
MCO PIHP - Community First Choice
18B2
d
MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
18C
Medicaid Health Insurance Payments: Group Health
Plan Payments
18D
Medicaid Health Insurance Payments: Coinsurance
And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services - Regular
Payment (Waiver)
19B
Home and Community-Based Services - State Plan
1915(i) Only Payment
19C
Home and Community-Based Services - State Plan
1915(j) Only Payment
19D
Home and Community Based Services State Plan
1915(k) Community First Choice
22
Programs Of All-Inclusive Care Elderly
23A
Personal Care Services - Regular Payment
23B
Personal Care Services - SDS 1915(j)
24A
Targeted Case Management Services - Community
Case-Management
24B
Case Management - State Wide
25
Primary Care Case Management Services
26
Hospice Benefits
27
Emergency Services for Undocumented Aliens
Form CMS 64.9T Waiver
Applied Against
the 20% Limit
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Medical Assistance Payments
Waiver Type:
Waiver Name:
Waiver Number:
Medicaid and CHIP Medicaid FMAP
FMAP
Total Computable
(A)
28
Federally-Qualified Health Center
29
Non-Emergency Medical Transportation
30
Physical Therapy
31
Occupational Therapy
32
Services for Speech, Hearing and Language
33
Prosthetic Devices, Dentures, Eyeglasses
34
Diagnostic Screening & Preventive Services
34A
Preventive Services Grade A OR B, ACIP Vaccines
and their Admin
35
Nurse Mid-Wife
36
Emergency Hospital Services
37
Critical Access Hospitals
38
Nurse Practitioner Services
39
School Based Services
40
Rehabilitative Services (non-school-based)
41
Private Duty Nursing
42
Freestanding Birth Center
43
Health Home for Enrollees w Chronic Conditions
44
Tobacco Cessation for Preg Women
49
Other Care Services
50
Total
Form CMS 64.9T Waiver
Applied Against
the 20% Limit
Enhanced FMAP
(B)
Incr FMAP
(C)
CHIP Amount
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Fraud, Waste & Abuse Amounts Credited
From Medicaid Program Integrity Activities
State:
Medical Assistance Payments
Total
Computable
Medicaid
Federal Share
ARRA Federal
Share
BIPP Federal
Share
Federal Share
(A)
(B)
(C)
(D)
(E)
1. Amounts Identified from State PI activities
1A. Data mining activities
1B. PI Provider audits
1C. Other
2. MFCU Investigations
3. Settlements/Judgments
4. Civil Monetary Penalties
5. CMS Medicaid Integrity Contractors (MICs)
6. Other
50. 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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments
Period
Total
Computable
FMAP
Rate
Medicaid
Federal Share
BIPP
Rate
BIPP Federal
Share
Total Federal
Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
1. Recoveries from OIG Certified Compliant FCA
1A. Total Recovery
1A1. Total Recovery
1A2. Total Recovery
1A3. Total Recovery
1A4. Total Recovery
1A5. Total Recovery
1A6. Total Recovery
1A7. Total Recovery
1A8. Total Recovery
1A9. Total Recovery
1A10. Total Recovery
1A11. Total Recovery
1A12. Total Recovery
1A13. Total Recovery
1A14. Total Recovery
1A15. Total Recovery
1A16. Total Recovery
*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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments
Period
Total
Computable
FMAP
Rate
Medicaid
Federal Share
BIPP
Rate
BIPP Federal
Share
Total Federal
Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
1A17. Total Recovery
1A18. Total Recovery
1A19. Total Recovery
1A20. Total Recovery
1A21. Total Recovery
1A22. Total Recovery
1A23. Total Recovery
1A24. Total Recovery
1A25. Total Recovery
1B. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B1. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B2. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B3. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B4. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B5. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B6. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B7. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B8. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
*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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments
Period
Total
Computable
FMAP
Rate
Medicaid
Federal Share
BIPP
Rate
BIPP Federal
Share
Total Federal
Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
1B9. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B10. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B11. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B12. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B13. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B14. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B15. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B16. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B17. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B18. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B19. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B20. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B21. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B22. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B23. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B24. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1B25. Recovery after 10% FMAP reduction to any amounts
recovered under a State action brought under an OIG
approved State law
1C. 10% Reduction FMAP Rate (to be used in the grant
award computation)
*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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments
Period
Total
Computable
FMAP
Rate
Medicaid
Federal Share
BIPP
Rate
BIPP Federal
Share
Total Federal
Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
1C1. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C2. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C3. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C4. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C5. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C6. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C7. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C8. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C9. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C10. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C11. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C12. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C13. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C14. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C15. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C16. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C17. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C18. 10% Reduction FMAP Rate (to be used in the grant
award computation)
*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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments
Period
Total
Computable
FMAP
Rate
Medicaid
Federal Share
BIPP
Rate
BIPP Federal
Share
Total Federal
Share
(A)
(B)
(C)
(D)
(E)
(F)
(G)
1C19. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C20. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C21. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C22. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C23. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C24. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C25. 10% Reduction FMAP Rate (to be used in the grant
award computation)
*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
Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0937-0067
Expires 04/30/2014
Allocation of Qualified Individual Part B (QIB) Benefits.
Payment Adjustments to Applicable FFYs
State:
Quarter Ended:
Total Computable
(A)
Federal Share
(B)
FFY 2010 (10/01/2009 - 09/30/2010)
1
FFY 2010 Allotment
2
Amount Previously Reported - Title XIX
3
Line 6 - Title XIX
4
Line 7 - Title XIX
5
Line 8 - Title XIX
6
Line 10 - Title XIX
7
Subtotal - Title XIX
8
Total To Date - Title XIX
9
Unused FFY 2010 Allotment
FFY 2011 (10/01/2010 - 09/30/2011)
1
FFY 2011 Allotment
2
Amount Previously Reported - Title XIX
3
Line 6 - Title XIX
4
Line 7 - Title XIX
5
Line 8 - Title XIX
6
Line 10 - Title XIX
7
Subtotal - Title XIX
8
Total To Date - Title XIX
9
Unused FFY 2011 Allotment
FFY 2012 (10/01/2011 - 09/30/2012)
1
FFY 2012 Allotment
2
Amount Previously Reported - Title XIX
3
Line 6 - Title XIX
4
Line 7 - Title XIX
5
Line 8 - Title XIX
6
Line 10 - Title XIX
7
Subtotal - Title XIX
8
Total To Date - Title XIX
9
Unused FFY 2012 Allotment
FFY 2013 (10/01/2012 - 09/30/2013)
1
FFY 2013 Allotment
2
Amount Previously Reported - Title XIX
3
Line 6 - Title XIX
4
Line 7 - Title XIX
5
Line 8 - Title XIX
6
Line 10 - Title XIX
7
Subtotal - Title XIX
8
Total To Date - Title XIX
9
Unused FFY 2013 Allotment
Form CMS 64.9QI
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Optional
Total
Comp.
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9PE
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(D)
(E)
(F)
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
(B)
Federal Share
Total
Federal
Share
Clinic Services
17A
17C1
(A)
Other %
(Oth)
Dental Services
Other Practitioners Services - Regular
Payments
11
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Increased ACA OFFSET - MCO - 100%
9A
10
Optional
Total
Comp.
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9PE
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
18B1
c
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9PE
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9PE
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(B)
(C)
(D)
(E)
(F)
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
(A)
Federal
Share
Total
Federal
Share
Nursing Facility Services - Regular Payments
3B
5D
Incr FMAP
Other %
(Oth)
Inpatient Hospital Services - GME Payments
2A
3A
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9PEP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
7A4
7A5
7A6
8
14
15
16
18A2
18A3
(G)
(H)
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part B
Premiums
18A1
(F)
Home Health Services
17B
18A
(E)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part A
Premiums
17D
(D)
Clinic Services
17A
17C1
(C)
Dental Services
Other Practitioners Services - Supplemental
Payments
13
(B)
Deferral
Or
C.I.N.
Number
Increased ACA OFFSET - MCO - 100%
9B
12
(A)
Federal
Share
Total
Federal
Share
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Incr FMAP
Other %
(Oth)
MCO - State Sidebar Agreement
9A
10
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9PEP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(C)
(D)
(E)
(F)
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
(B)
Deferral
Or
C.I.N.
Number
MCO PAHP - Evaluation and Management
18D
23A
(A)
Federal
Share
Total
Federal
Share
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Incr FMAP
Other %
(Oth)
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9PEP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9PEP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
43
44
49
50
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9PEP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
Total
Comp.
Incr FMAP
(A)
(B)
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Nursing Facility Services - Regular Payments
3B
5D
FMAP
Inpatient Hospital Services - GME Payments
2A
3A
Federal Share
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9PEP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
7A4
7A5
7A6
8
14
15
16
18A2
18A3
(D)
(E)
(F)
(G)
(H)
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part B
Premiums
18A1
(C)
Home Health Services
17B
18A
(B)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part A
Premiums
17D
(A)
Federal
Share
Deferral
Or
C.I.N.
Number
Clinic Services
17A
17C1
Incr FMAP
Total
Federal
Share
Dental Services
Other Practitioners Services - Supplemental
Payments
13
Total
Comp.
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9B
12
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
FMAP
MCO - State Sidebar Agreement
9A
10
Federal Share
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9PEP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
Incr FMAP
(A)
(B)
(C)
(D)
(E)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
Total
Comp.
Other %
(Oth)
MCO PAHP - Evaluation and Management
18D
23A
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
FMAP
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Federal Share
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9PEP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Federal Share
FMAP
Optional
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9PEP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
43
44
49
50
Federal Share
FMAP
Optional
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9PEP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Quarter Ended:
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9PE Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(B)
(C)
(D)
(E)
Federal Share
(F)
Total
Federal
Share
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(A)
Other %
(Oth)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Clinic Services
17A
17C1
Optional
Total
Comp.
Dental Services
Other Practitioners Services - Regular
Payments
11
Federal Share
Increased ACA OFFSET - MCO - 100%
9A
10
Quarter Ended:
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9PE Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
18B1
c
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9PE Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9PE Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Optional
Total
Comp.
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9E
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(D)
(E)
(F)
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
(B)
Federal Share
Total
Federal
Share
Clinic Services
17A
17C1
(A)
Other %
(Oth)
Dental Services
Other Practitioners Services - Regular
Payments
11
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Increased ACA OFFSET - MCO - 100%
9A
10
Optional
Total
Comp.
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9E
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
18B1
c
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9E
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Medical Assistance Payments
Federal Share
Special Issue Reporting Program:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9E
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(B)
(C)
(D)
(E)
(F)
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
(A)
Federal
Share
Total
Federal
Share
Nursing Facility Services - Regular Payments
3B
5D
Incr FMAP
Other %
(Oth)
Inpatient Hospital Services - GME Payments
2A
3A
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9EP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
7A4
7A5
7A6
8
14
15
16
18A2
18A3
(G)
(H)
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part B
Premiums
18A1
(F)
Home Health Services
17B
18A
(E)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part A
Premiums
17D
(D)
Clinic Services
17A
17C1
(C)
Dental Services
Other Practitioners Services - Supplemental
Payments
13
(B)
Deferral
Or
C.I.N.
Number
Increased ACA OFFSET - MCO - 100%
9B
12
(A)
Federal
Share
Total
Federal
Share
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Incr FMAP
Other %
(Oth)
MCO - State Sidebar Agreement
9A
10
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9EP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(C)
(D)
(E)
(F)
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
(B)
Deferral
Or
C.I.N.
Number
MCO PAHP - Evaluation and Management
18D
23A
(A)
Federal
Share
Total
Federal
Share
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Incr FMAP
Other %
(Oth)
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Total
Comp.
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9EP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9EP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Federal Share
FMAP
Special Issue Reporting Program:
Optional
43
44
49
50
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9EP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
Total
Comp.
Incr FMAP
(A)
(B)
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Nursing Facility Services - Regular Payments
3B
5D
FMAP
Inpatient Hospital Services - GME Payments
2A
3A
Federal Share
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9EP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
7A4
7A5
7A6
8
14
15
16
18A2
18A3
(D)
(E)
(F)
(G)
(H)
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part B
Premiums
18A1
(C)
Home Health Services
17B
18A
(B)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part A
Premiums
17D
(A)
Federal
Share
Deferral
Or
C.I.N.
Number
Clinic Services
17A
17C1
Incr FMAP
Total
Federal
Share
Dental Services
Other Practitioners Services - Supplemental
Payments
13
Total
Comp.
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9B
12
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
FMAP
MCO - State Sidebar Agreement
9A
10
Federal Share
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9EP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
Incr FMAP
(A)
(B)
(C)
(D)
(E)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
Total
Comp.
Other %
(Oth)
MCO PAHP - Evaluation and Management
18D
23A
Optional
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
FMAP
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Federal Share
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9EP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Federal Share
FMAP
Optional
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9EP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Eligibility:
43
44
49
50
Federal Share
FMAP
Optional
Total
Comp.
Incr FMAP
(A)
(B)
IHS
Breast or
Facility Fam. Plan
Cerv.
Services Services
Cancer
90%
Services *
100%
(C)
(D)
(E)
Other %
(Oth)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9EP Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Quarter Ended:
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9E Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(B)
(C)
(D)
(E)
Federal Share
(F)
Total
Federal
Share
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(A)
Other %
(Oth)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Clinic Services
17A
17C1
Optional
Total
Comp.
Dental Services
Other Practitioners Services - Regular
Payments
11
Federal Share
Increased ACA OFFSET - MCO - 100%
9A
10
Quarter Ended:
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9E Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
18B1
c
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9E Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9E Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
64.S9RAC - RAC Collections
Quarter Ended:
State:
Total Computable
(A)
1
2
3
4
5
6
7
Medicaid Federal
Share
(B)
ARRA Federal
Share
(C)
BIPP Federal
Share
(D)
Total Federal
Share
(E)
Collections Not Previously Reported on CMS-64.9ORAC
Collections on Overpayment previously reported on CMS-64.9ORAC
Total Collections
RAC CONTINGENCY FEES DEDUCTED FROM COLLECTIONS
COLLECTIONS LESS FEES
LESS PREVIOUSLY REPORTED ON 64.9ORAC. (Line 2)
NET COLLECTIONS
Form: CMS 64.S9RAC
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Quarter Ended:
Expenditures Reported for Period
by Form Number
Medical Assistance Payment and Medicaid CHIP
State and Local Administration
Federal Share
Federal Share
(A)
(B)
FFY
1.
FY YYYY CAP
2.
Amount Previously reported
6.
Expenditures in this Quarter
6.A. From Form CMS-64.9/CMS-64.10
6.A.1. From Form CMS-64.9T
6.A.2. From Form CMS-64.9E/CMS-64.9PE
6.B. From Form CMS-64.21
6.C. From Form CMS-64.21U
7.
Adjustments Increasing Claims for Prior Quarters
7.A. From Form CMS 64.9P/CMS 64.10P
7.A.1. From Form CMS-64.9TP
7.A.2. From Form CMS-64.9EP/CMS-64.9PEP
7.B. From Form CMS-64.21P
7.C. From Form CMS-64.21UP
8.
Other Expenditures
8.A. From Form CMS 64.9P/CMS 64.10P
8.A.1. From Form CMS-64.9TP
8.A.2. From Form CMS-64.9EP/CMS-64.9PEP
8.B. From Form CMS-64.21P
8.C. From Form CMS-64.21UP
10A.
Adjustments Decreasing Claims for Prior Quarters:
A.
Federal Audit
10.A.1. From Form CMS 64.9P/CMS 64.10P
10.A.1.a. From Form CMS-64.9TP
10.A.1.b. From Form CMS-64.9EP/CMS-64.9PEP
10.A.2. From Form CMS 64.21P
10.A.3. From Form CMS 64.21UP
10B.
Adjustments Decreasing Claims for Prior Quarters:
B.
Federal Audit
10.B.1. From Form CMS 64.9P/CMS 64.10P
10.B.1.a. From Form CMS-64.9TP
10.B.1.b. From Form CMS-64.9EP/CMS-64.9PEP
10.B.2. From Form CMS 64.21P
10.B.3. From Form CMS 64.21UP
11.
Net Expenditures Reported This Period
12.
Unused CAP
Form CMS 64 1108CAP
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Cost of
In-House Activities
2B
Design Development Or Installation Of MMIS: Cost of
Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Costs of In-House
Activities Plus State Agencies And Institutions
4B
Operation Of An Approved MMIS: Cost of Private
Sector Contractors
5A
Mechanized Systems, Not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training Costs
10
Preadmission Screening Costs
11
Resident Review Activities Costs
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary 90%
16
TANF Secondary 75%
17
External Review
18
Enrollment Brokers
19
School Based Administration
Form CMS 64.10 200K
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures In This Quarter
State:
Quarter Ended:
Federal Share
Total
Computable
(A)
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs (State Level)
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10 200K
FFP
Rate
Federal
Share
(B)
0.0%
Federal
Share
(C)
Total
Federal
Share
(D)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
1
Family Planning
2A
Design Development Or Installation Of MMIS: Costs
Of In-House Activities
2B
Design Development Or Installation Of MMIS: Costs
Of Private Sector Contractors
3A
Skilled Professional Medical Personnel-Single State
Agency
3B
Skilled Professional Medical Personnel - Other
Agency
4A
Operation Of An Approved MMIS: Cost Of In-House
Activities
4B
Operation Of An Approved MMIS: Cost Of Private
Sector Contractors
5A
Mechanized Systems, not Approved Under MMIS
Procedures: Costs Of In-House Activities
5B
Mechanized Systems, Not Approved Under MMIS
Procedures: Cost Of Private Sector Contractors
5C
Mechanized Systems - Not Approved under MMIS
Procedures: Interagency
6
Quality Improvement Organizations
7A
Third Party Liability: Recovery Procedure - Billing
Offset
7B
Third Party Liability: Assignment Of Rights - Billing
Offset
8
Immigration Status Verification System Costs (100%
FFP)
9
Nurse Aide Training
10
Preadmission Screening Costs
11
Resident Review Activities Cost
12
Drug Use Review Program
13
Outstationed Eligibility Workers
14
TANF Base
15
TANF Secondary (90%)
Form CMS 64.10P 200K
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
16
TANF Secondary (75%)
17
External Review
18
Enrollment Brokers
19
School Based Administration
20
Program Integrity/Fraud, Waste, and Abuse Activities
21
County/Local ADM Costs
22
Interagency Costs
23
Translation and Interpretation
24
Health Information Technology Administration
24A
HIT: Planning: Cost of In-house Activities
24B
HIT: Planning: Cost of Private Contractors
24C
HIT: Implementation and Operation: Cost of In-house
Activities
24D
HIT: Implementation and Operation: Cost of Private
Contractors
24E
HIT Incentive Payments - Eligible Professionals
24F
HIT Incentive Payments - Eligible Hospitals
25
Citizenship Verification Technology - CHIPRA
25A
CVT Development - CHIPRA
25B
CVT Operation - CHIPRA
26
Planning for Health Homes for Enrollees with Chronic
Conditions
27
Recovery Audit Contractors State Administration
28A
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of In-house Activities
Form CMS 64.10P 200K
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Prior Period Adjustments
State:
Quarter Ended:
Prior Fiscal Year:
Line #
Federal Share
Total
Computable
(A)
28B
Design Development/Installation of Medicaid Elig.
Determ. Sys. – Cost of Private Sec. Contractors
28C
Operation of an Approved Medicaid Eligibility
Determination Systems – Cost of In-house Activities
28D
Operation of an Approved Medicaid Eligibility
Determination Sys. – Cost of Private Sec. Contractors
29
Other Financial Participation
30
Total
Form CMS 64.10P 200K
FFP
Rate
Federal
Share
(B)
Federal
Share
0.0%
(C)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(D)
(E)
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Quarter Ended:
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9 WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
FMAP
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
Total
Comp.
Other %
(Oth)
Clinic Services
17A
17C1
Other & Prompt Pay
Optional
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Dental Services
Other Practitioners Services - Regular
Payments
11
Federal Share
Increased ACA OFFSET - MCO - 100%
9A
10
Quarter Ended:
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9 WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
18B1
c
Quarter Ended:
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9 WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Quarter Ended:
Federal Share
Other & Prompt Pay
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
FMAP
Other %
(Oth)
Nursing Facility Services - Regular Payments
3B
5D
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Inpatient Hospital Services - GME Payments
2A
3A
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Inpatient Hospital Services: Regular Payments
1B
1D
Federal Share
Prescribed Drugs
Drug Rebate - National Agreement
Drug Rebate - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9P WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
7A4
7A5
7A6
8
14
15
16
(D)
(E)
(F)
(G)
(H)
Home Health
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Clinic Services
17A
18A1
(A)
Prompt Pay
(PP)
Total
Federal
Share
Dental Services
Other Practitioners Services - Supplemental
Payments
13
FMAP
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9B
12
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
MCO - State Sidebar Agreement
9A
10
Federal Share
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9P WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
FMAP
Other %
(Oth)
MCO PAHP - Evaluation and Management
18D
23A
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Federal Share
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9P WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9P WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
DSH Allotment Year:
43
44
49
50
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9P WAIV DSH Diversion
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
1A
Inpatient Hospital Services - Regular
Payments
1B
Inpatient Hospital Service - DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
1D
Mental Health Facility Services - Regular
Payments
2B
Mental Health Facility Services - DSH
Adjustment Payments
3A
Nursing Facility Services - Regular
Payments
3B
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services Mentally Retarded: Public Providers
4B
Intermediate Care Facility Services Mentally Retarded: Private Providers
4C
Intermediate Care Facility Services Mentally Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation
and Management
5D
Physician & Surgical Services - Vaccine
codes
6A
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
7A4
7A5
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Inpatient Hospital Services - GME Payments
2A
7
Quarter Ended:
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement
MCO - State Sidebar Agreement
Increased ACA OFFSET - Fee for Service 100%
Form CMS 64.9I DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
7A6
8
9B
Other Practitioners Services - Supplemental
Payments
12
13
14
15
16
(B)
(C)
(D)
(E)
Federal Share
(F)
Total
Federal
Share
(G)
Home Health Services
Sterilizations
Abortions No.
EPSDT Screening Services
Rural Health Clinic Screening
17B
Medicare Health Insurance Payments - Part
B Premiums
18A
(A)
Other %
(Oth)
Laboratory And Radiological Services
Medicare Health Insurance Payments - Part
A Premiums
17D
FMAP
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
Clinic Services
17A
17C1
Optional
Total
Comp.
Dental Services
Other Practitioners Services - Regular
Payments
11
Federal Share
Increased ACA OFFSET - MCO - 100%
9A
10
Quarter Ended:
120% - 134% Of Poverty
Coinsurance And Deductibles
Medicaid Health Insurance Payments:
Managed Care Organizations (MCO)
Medicaid MCO - Evaluation and
18A1 Management
18A2
18A3
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services Grade
18A4 A OR B, ACIP Vaccines and their Admin
18B1
18B1
a
18B1
b
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
Form CMS 64.9I DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
18B1
c
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A
18B1 OR B, ACIP Vaccines and their Admin
d
18B2
18B2
a
18B2
b
18B2
c
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A
18B2 OR B, ACIP Vaccines and their Admin
d
18C
Medicaid Health Insurance Payments:
Group Health Plan Payments
18D
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
18E
Medicaid Health Insurance Payments: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services State Plan 1915(i) Only Payment
19C
Home and Community-Based Services State Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
22
23A
23B
24A
24B
25
26
27
28
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
Primary Care Case Management Services
Hospice Benefits
Emergency Services for Undocumented
Aliens
Federally-Qualified Health Center
Form CMS 64.9I DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
Quarter Ended:
Federal Share
Optional
Total
Comp.
FMAP
(A)
(B)
IHS Facility Fam. Plan.
Breast or
Services
Services Cerv. Cancer
100%
90%
Services
(C)
(D)
(E)
Other %
(Oth)
Federal Share
(F)
Total
Federal
Share
(G)
Non-Emergency Medical Transportation
Physical Therapy
Occupational Therapy
Services for Speech, Hearing and Language
Prosthetic Devices, Dentures, Eyeglasses
Diagnostic Screening & Preventive Services
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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 64.9I DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
1A
Inpatient Hospital Services: DSH Adjustment
Payments
1C
Inpatient Hospital Services - Supplemental
Payments
Mental Health Facility Services: Regular
Payments
2B
Mental Health Facility Services: DSH
Adjustment Payments
Nursing Facility Services - Supplemental
Payments
4A
Intermediate Care Facility Services - Mentally
Retarded: Public Providers
4B
Intermediate Care Facility Services - Mentally
Retarded: Private Providers
4C
Intermediate Care Facility Services - Mentally
Retarded: Supplemental Payments
5A
Physician and Surgical Services - Regular
Payments
5B
Physician and Surgical Services Supplemental Payments
5C
Physician & Surgical Services - Evaluation and
Management
Outpatient Hospital Services - Regular
Payments
6B
Outpatient Hospital Services - Supplemental
Payments
7A1
7A2
7A3
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Physician & Surgical Services - Vaccine codes
6A
7
FMAP
Other %
(Oth)
Nursing Facility Services - Regular Payments
3B
5D
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Inpatient Hospital Services - GME Payments
2A
3A
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Inpatient Hospital Services: Regular Payments
1B
1D
Federal Share
Prescribed Drugs
Drug Rebate Offset - National Agreement
Drug Rebate Offset - State Sidebar Agreement
MCO - National Agreement
Form CMS 64.9PI DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
7A4
7A5
7A6
8
14
15
16
(D)
(E)
(F)
(G)
(H)
Home Health Services
Sterilizations
Abortions
EPSDT Screening Services
Rural Health Clinic Services
17B
Medicare Health Insurance Payments: Part B
Premiums
17C1
Medicare Health Insurance Payments:
Qualifying Individuals/120% - 134% of Poverty
17D
Medicare Health Insurance Payments:
Coinsurance and Deductibles
18A
Medicaid Health Insurance Payments:
Managed Care Organizations
18A3
(C)
Laboratory And Radiological Services
Medicare Health Insurance Payments: Part A
Premiums
18A2
(B)
Federal
Share
Deferral
Or
C.I.N.
Number
Clinic Services
17A
18A1
(A)
Prompt Pay
(PP)
Total
Federal
Share
Dental Services
Other Practitioners Services - Supplemental
Payments
13
FMAP
Other %
(Oth)
Increased ACA OFFSET - MCO - 100%
9B
12
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Increased ACA OFFSET - Fee for Service 100%
Other Practitioners Services - Regular
Payments
11
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
MCO - State Sidebar Agreement
9A
10
Federal Share
Medicaid MCO - Evaluation and Management
Medicaid MCO - Vaccine codes
Medicaid MCO - Community First Choice
Form CMS 64.9PI DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
18A4
18B1
18B1
a
18B1
b
18B1
c
18B1
d
18B2
18B2
a
18B2
b
18B2
c
18B2
d
(A)
(B)
(C)
(D)
(E)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Prepaid Inpatient Health Plan
MCO PIHP - Evaluation and Management
MCO PIHP - Vaccine codes
MCO PIHP - Community First Choice
MCO PIHP - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin
Medicaid Health Insurance Payments:
Coinsurance and Deductibles
Medicaid Health Insurance Program: Other
19A
Home and Community-Based Services Regular Payment (Waiver)
19B
Home and Community-Based Services - State
Plan 1915(i) Only Payment
19C
Home and Community-Based Services - State
Plan 1915(j) Only Payment
19D
Home and Community Based Services State
Plan 1915(k) Community First Choice
23B
FMAP
Other %
(Oth)
MCO PAHP - Evaluation and Management
18D
23A
Total
Comp.
IHS
Facility Fam. Plan
Services Services
90%
100%
Prepaid Ambulatory Health Plan
Medicaid Health Insurance Payments: Group
Health Plan Payments
22
Other & Prompt Pay
Optional
Breast or
Cerv.
Cancer
Services *
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
18C
18E
Federal Share
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Personal Care Services - SDS 1915(j)
Form CMS 64.9PI DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Targeted Case Management Services Community Case-Management
Case Management - State Wide
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
Preventive Services Grade A OR B, ACIP
Vaccines and their Admin
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
Form CMS 64.9PI DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-0067
Expires 04/30/2014
Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Prior Period Adjustments In This Quarter
State:
Quarter Ended:
Fiscal Year:
Line #
Medical Assistance Payments
Waiver Type:
Waiver Number:
Waiver Name:
Program: DSH Excess Expenditure
DSH Allotment Year:
43
44
49
50
Federal Share
Other & Prompt Pay
Total
Comp.
FMAP
(A)
(B)
IHS
Facility Fam. Plan
Services Services
90%
100%
(C)
(D)
Optional
Breast or
Cerv.
Cancer
Services *
(E)
Other %
(Oth)
Prompt Pay
(PP)
Federal
Share
(F)
Total
Federal
Share
Deferral
Or
C.I.N.
Number
(G)
(H)
Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women
Other Care Services
Total
Form CMS 64.9PI DSH Diversion Waiver
Report Date: Friday, February 01, 2013 - 02:57 PM
| File Type | application/pdf |
| File Modified | 2013-02-01 |
| File Created | 0000-00-00 |