CMS-64.9i Expenditures

Appendix F
OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

M E D I C AL AS S I S T AN C E E X P E N D I T U R E S B Y T Y P E O F S E R VI C E
F O R T H E M E D I C AL AS S I S T AN C E P R O GR AM
E X P E N D I T U R E S I N T H I S Q U AR T E R

STATE
AGENCY
QUARTER ENDED

FEDERAL SHARE
MEDICAL ASSISTANCE PAYMENTS
SPECIAL ISSUES REPORTING

TOTAL
COMPUTABLE

TYPE OF PROGRAM _______________________
(a)
1. INPATIENT HOSPITAL SERVICES
A. Regular Payments

FMAP

I.H.S. FACILITY

FAMILY PLANNING

BREAST & CERVICAL

_____%

SERVICES

SERVICES

CANCER

100%

90%

(c)

(d)

(b)

TOTAL

PRESUMPTIVE ELIGIBILITY ____%

Enhanced
I.H.S.

(e)

(f)

FEDERAL

FEDERAL

SHARE

SHARE
(g)

B. DSH Adjustment Payments
2. MENTAL HEALTH FACILITY SERVICES
A. Regular Payments
B. DSH Adjustment Payments
3. NURSING FACILITY SERVICES
4. INTERMEDIATE CARE FACILITY SERVICES
- MENTALLY RETARDED:
A. PUBLIC PROVIDERS
B. PRIVATE PROVIDERS
5. PHYSICIANS' SERVICES
6. OUTPATIENT HOSPITAL SERVICES
7. PRESCRIBED DRUGS
7A. DRUG REBATE OFFSET
1. NATIONAL AGREEMENT
2. STATE SIDEBAR AGREEMENT
8. DENTAL SERVICES
9. OTHER PRACTITIONERS' SERVICES
10. CLINIC SERVICES
11. LABORATORY AND RADIOLOGICAL SERVICES
12. HOME HEALTH SERVICES
13. STERILIZATIONS

FORM CMS-64.9I

DRAFT

PAGE 1 OF 2

Appendix F
OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

M E D I CA L A S S I S T A N CE E XP E N D I T U R E S B Y T Y P E OF S E R V I CE
FOR T H E M E D ICAL AS S IS T ANCE P R OGR AM
E XP E N D I T U R E S I N T H I S QU A R T E R

STATE
AGENCY
QUARTER ENDED
FE D E R AL S H AR E

MEDICAL ASSISTANCE PAYMENTS
SPECIAL ISSUES REPORTING

TOTAL
COMPUTABLE

TYPE OF PROGRAM _______________________
(a)
14. ABORTIONS

FMAP

I.H.S. FACILITY

FAMILY PLANNING

BREAST & CERVICAL

_____%

SERVICES

SERVICES

CANCER

100%

90%

PRESUMPTIVE ELIGIBILITY

(c)

(d)

(e)

(b)

TOTAL
____%
(f)

FEDERAL

FEDERAL

SHARE

SHARE
(g)

NO. ______

15. EPSDT SCREENING SERVICES
16. RURAL HEALTH CLINIC SERVICES
17. MEDICARE HEALTH INSURANCE PAYMENTS:
(A) PART A PREMIUMS
(B) PART B PREMIUMS
(C) QUALIFYING INDIVIDUALS
(1) 120% -134% OF POVERTY
(2) 135% -175% OF POVERTY
(D) COINSURANCE AND DEDUCTIBLES
18. MEDICAID HEALTH INSURANCE PAYMENTS:
(A) MANAGED CARE ORGANIZATIONS (MCO)
(B) PREPAID HEALTH PLANS (PHP)
(C) GROUP HEALTH PLAN PAYMENTS
(D) COINSURANCE AND DEDUCTIBLES
(E) OTHER
19. HOME AND COMMUNITY-BASED SERVICES 1
20. H&CB CARE FOR FUNCTIONALLY
DISABLED ELDERLY
21. COMMUNITY SUPPORTED LIVING SERVICES
22. PROGRAMS OF ALL-INCLUSIVE CARE ELDERLY
23. PERSONAL CARE SERVICES
24. TARGETED CASE MANAGEMENT SERVICES
25. PRIMARY CARE CASE MANAGEMENT SERVICES
26. HOSPICE BENEFITS
27. EMERGENCY SERVICES UNDOCUMENTED ALIENS
28. FEDERALLY-QUALIFIED HEALTH CENTER
29. OTHER CARE SERVICES
30. TOTAL (ENTER COLUMNS (a) AND (f) ON
SUMMARY SHEET, LINE 7, 8, 10.A. OR 10.B.,
COLUMNS (a) AND (b) AS APPROPRIATE).
1 IF STATE HAS MORE THAN ONE APPROVED HCBS WAIVER, ATTACH SCHEDULE SHOWING EXPENDITURES FOR EACH APPROVED WAIVER

FORM CMS-64.9I

DRAFT

PAGE 2 OF 2

Appendix F
OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

M E DI CAL AS S I S T AN CE E X P E N DI T UR E S B Y T YP E O F S E R VI CE
F O R T HE M E DI CAL AS S I S T AN CE P R O GR AM
PRIOR PERIOD ADJUSTMENTS I N T H I S Q U A R T E R
CHECK ONE:

LINE 7

STATE
QUARTER ENDED
FISCAL YEAR

LINE 8

LINE 10A

LINE 10B

FE D E R AL S H AR E
MEDICAL ASSISTANCE PAYMENTS
SPECIAL ISSUES REPORTING

TOTAL
COMPUTABLE

TYPE OF PROGRAM _______________________
(a)
1. INPATIENT HOSPITAL SERVICES
A. Regular Payments

FMAP

I.H.S. FACILITY

FAMILY PLANNING

BREAST & CERVICAL

_____%

SERVICES

SERVICES

CANCER

100%

90%

PRESUMPTIVE ELIGIBILITY

(c)

(d)

(e)

(b)

Enhanced
I.H.S.

TOTAL
____%
(f)

FEDERAL

FEDERAL

SHARE

SHARE
(g)

B. DSH Adjustment Payments
2. MENTAL HEALTH FACILITY SERVICES
A. Regular Payments
B. DSH Adjustment Payments
3. NURSING FACILITY SERVICES
4. INTERMEDIATE CARE FACILITY SERVICES
- MENTALLY RETARDED:
A. PUBLIC PROVIDERS
B. PRIVATE PROVIDERS
5. PHYSICIANS' SERVICES
6. OUTPATIENT HOSPITAL SERVICES
7. PRESCRIBED DRUGS
7A. DRUG REBATE OFFSET
1. NATIONAL AGREEMENT
2. STATE SIDEBAR AGREEMENT
8. DENTAL SERVICES
9. OTHER PRACTITIONERS' SERVICES
10. CLINIC SERVICES
11. LABORATORY AND RADIOLOGICAL SERVICES
12. HOME HEALTH SERVICES
13. STERILIZATIONS

FORM CMS-64.9PI

DRAFT

PAGE 1 OF 2

DEFERRAL
OR
C.I.N.
NUMBER
{h}

Appendix F
OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION

M E D ICAL AS S IS T AN CE E XP E N D IT U R E S B Y T YP E OF S E R VICE
FOR T H E M E D ICAL AS S IS T ANCE P R OGR AM
PRIOR PERIOD ADJUSTMENTS I N T H I S Q U A R T E R
CHECK ONE:

LINE 7

STATE
QUARTER ENDED
FISCAL YEAR
LINE 8

LINE 10A

LINE 10B

TOTAL
MEDICAL ASSISTANCE PAYMENTS

COMPUTABLE

SPECIAL ISSUES REPORTING

FMAP

I.H.S. FACILITY

FAMILY PLANNING

_____%

SERVICES

SERVICES

CANCER

100%

90%

PRESUMPTIVE ELIGIBILITY

(c)

(d)

(e)

TYPE OF PROGRAM _______________________
(a)

(b)

BREAST & CERVICAL

TOTAL
____%
(f)

FEDERAL

FEDERAL

SHARE

SHARE
(g)

15. EPSDT SCREENING SERVICES
16. RURAL HEALTH CLINIC SERVICES
17. MEDICARE HEALTH INSURANCE PAYMENTS:
(A) PART A PREMIUMS
(B) PART B PREMIUMS
(C) QUALIFYING INDIVIDUALS
(1) 120% -134% OF POVERTY
(2) 135% -175% OF POVERTY
(D) COINSURANCE AND DEDUCTIBLES
18. MEDICAID HEALTH INSURANCE PAYMENTS:
(A) MANAGED CARE ORGANIZATIONS (MCO)
(B) PREPAID HEALTH PLANS (PHP)
(C) GROUP HEALTH PLAN PAYMENTS
(D) COINSURANCE AND DEDUCTIBLES
(E) OTHER
19. HOME AND COMMUNITY-BASED SERVICES 1
20. H&CB CARE FOR FUNCTIONALLY
DISABLED ELDERLY
21. COMMUNITY SUPPORTED LIVING SERVICES
22. PROGRAMS OF ALL-INCLUSIVE CARE ELDERLY
23. PERSONAL CARE SERVICES
24. TARGETED CASE MANAGEMENT SERVICES
25. PRIMARY CARE CASE MANAGEMENT SERVICES
26. HOSPICE BENEFITS
27. EMERGENCY SERVICES UNDOCUMENTED ALIENS
28. FEDERALLY-QUALIFIED HEALTH CENTER
29. OTHER CARE SERVICES
30. TOTAL (ENTER COLUMNS (a) AND (f) ON
SUMMARY SHEET, LINE 7, 8, 10.A. OR 10.B.,
COLUMNS (a) AND (b) AS APPROPRIATE).
1 IF STATE HAS MORE THAN ONE APPROVED HCBS WAIVER, ATTACH SCHEDULE SHOWING EX PENDITURES FOR EACH APPROVED WAIVER

FORM HCFA-64.9PI

DRAFT

PAGE 2 OF 2

DEFERRAL
OR
C.I.N.
NUMBER
{h}

Appendix F

OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

E X PE ND I TU R E S F OR S TA TE A ND L OCA L A D M I NI S TR A TI ON
F OR TH E M E D I CA L A S S I S TA NCE PR OG R A M
E X PE ND I TU R E S I N TH I S QU A R TE R
ADMINISTRATION

STATE
QUARTER ENDED

FEDER AL SHAR E

TOTAL

SPECIAL ISSUES REPORTING
TYPE OF PROGRAM _______________________
1. FAMILY PLANNING
2. DESIGN DEVELOPMENT OR INSTALLATION OF MMIS
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
C. DRUG CLAIMS SYSTEM
3. SKILLED PROFESSIONAL MEDICAL PERSONNEL
4. OPERATION OF AN APPROVED MMIS:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
5. MECHANIZED SYSTEMS, NOT APPROVED UNDER
MMIS PROCEDURES:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
6. PEER REVIEW ORGANIZATIONS (PRO)
7. A. THIRD PARTY LIABILITY
RECOVERY PROCEDURE - BILLING OFFSET
B. 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. OTHER FINANCIAL PARTICIPATION
20. TOTAL (ENTER COLUMNS (a) AND (f) ON SUMMARY
SHEET LINE 6 COLUMNS (c) AND (d))

DRAFT
FORM CMS-64.10I, (LINE 6)

TOTAL COMPUTABLE

90%

75%

50%

(a)

(b)

(c)

(d)

FEDERAL

FEDERAL

SHARE

SHARE

__%
(e)

(f)

Appendix F

OMB NO. 0938-0067

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

E X PE ND I TU R E S F OR S TA TE A ND L OCA L A D M I NI S TR A TI ON
F OR TH E M E D I CA L A S S I S TA NCE PR OG R A M
PR I OR PE R I OD A D J U S TM E NTS
ADMINISTRATION

LINE 7.

LINE 8.

SPECIAL ISSUES REPORTING
TYPE OF PROGRAM _______________________

STATE
QUARTER ENDED
FISCAL YEAR
LINE 10.A.

LINE 10.B.

FEDER AL SHAR E
TOTAL

COMPUTABLE

1. FAMILY PLANNING
2. DESIGN DEVELOPMENT OR INSTALLATION OF MMIS:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COSTS OF PRIVATE SECTOR CONTRACTORS
C. DRUG CLAIMS SYSTEM
3. SKILLED PROFESSIONAL MEDICAL PERSONNEL
4. OPERATION OF AN APPROVED MMIS:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
5. MECHANIZED SYSTEMS, NOT APPROVED UNDER
MMIS PROCEDURES:
A. COSTS OF IN-HOUSE ACTIVITIES PLUS OTHER
STATE AGENCIES AND INSTITUTIONS
B. COST OF PRIVATE SECTOR CONTRACTORS
6. PEER REVIEW ORGANIZATIONS (PRO)
7. A. THIRD PARTY LIABILITY
RECOVERY PROCEDURE - BILLING OFFSET
B. 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 COST
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. OTHER FINANCIAL PARTICIPATION
20. TOTAL (ENTER COLUMNS (a) AND (f) ON SUMMARY
SHEET LINE 7, 8, 10.A., OR 10.B. COLUMNS
(c) AND (d))

DRAFT
FORM CMS-64 10pI

DEFERRAL,

TOTAL

(a)

FEDERAL
90%
(b)

75%
(c)

50%
(d)

__% SHARE
(e)

DISALLOWANCE

FEDERAL

OR

SHARE
(f)

C.I.N. NO.
(g)