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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State: Colorado
Quarter Ended: 3/31/2017
Type of Eligible: Not Newly Disabled Person Non-Institutionalized
1A
1B
1C
1D
2A
2B
2C
3A
3B
4A
4B
4C
5A
5B
5C
5D
6A
6B
7
7A1
7A2
7A3
7A4
7A5
7A6
8
9A
9B
10
11
12
13
Family
Planning
Total
Computable FMAP
I.H.S. Services Services
Inpatient Hospital Services - Regular Payments
1,763,062
224,102
0
Inpatient Hospital Service - DSH Adjustment
Payments
0
0
0
Inpatient Hospital Services - Supplemental
Payments
0
0
0
Inpatient Hospital Services - GME Payments
0
0
0
Mental Health Facility Services - Regular
Payments
0
0
0
Mental Health Facility Services - DSH
Adjustment Payments
0
0
0
Certified Community Behaviorial Health Clinic
Payments
0
0
0
Nursing Facility Services - Regular Payments
29,187
3,710
0
Nursing Facility Services - Supplemental
Payments
0
0
0
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers
0
0
0
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers
0
0
0
Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Supplemental
Payments
0
0
0
Physician and Surgical Services - Regular
Payments
877,354
111,520
0
Physician and Surgical Services - Supplemental
Payments
0
0
0
Physician & Surgical Services - Evaluation and
Management
0
0
0
Physician & Surgical Services - Vaccine codes
0
0
0
Outpatient Hospital Services - Regular
Payments
865,782
110,049
0
Outpatient Hospital Services - Supplemental
Payments
0
0
0
Prescribed Drugs
1,487,808
189,114
0
Drug Rebate Offset - National Agreement
0
0
0
Drug Rebate Offset - State Sidebar Agreement
0
0
0
MCO - National Agreement
0
0
0
MCO - State Sidebar Agreement
0
0
0
Increased ACA OFFSET - Fee for Service - 100%
0
0
0
Increased ACA OFFSET - MCO - 100%
0
0
0
Dental Services
109,306
13,894
0
Other Practitioners Services - Regular
Payments
0
0
0
Other Practitioners Services - Supplemental
Payments
0
0
0
Clinic Services
19,633
2,495
0
Laboratory And Radiological Services
146,177
18,580
0
Home Health Services
304,882
38,753
0
Sterilizations
0
0
0
Form CMS 64.9VIII
Adjusted Total
Comp from
COL B minus
Resource Test
Adjusted Total
COL G Minus
Comp from Col
Enrollment
B minus
Total Comp
CAP COL I
Resource Test Special
Opt. Breast or Opt. Breast or
Total Comp
Total Comp
Col G minus
Resource Test Adjusted Total Enroll Cap
Cervical
Cervical
Circumstances minus Special
Circumstance Total Federal
Enrollment
Cancer Srvcs Cancer Srvcs
Comp from Col Applied to
Applied to
Applied to
Newly COL J COL K
Share
(ENH Rate)
(IHS Rate)
Other %
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
0
0
0
0.00
0
1,323,732
439,330
0
439,330
0
439,330
224,102
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0
0
0
21,914
0
7,273
0
0
0
7,273
0
0
0
7,273
0
3,710
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0.00
0
658,730
218,624
0
218,624
0
218,624
111,520
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
650,042
215,740
0
215,740
0
215,740
110,049
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
100.00
100.00
0.00
0
0
0
0
0
0
0
0
0
0
1,117,068
0
0
0
0
0
0
82,069
0
370,740
0
0
0
0
0
0
27,237
0
0
0
0
0
0
0
0
0
0
370,740
0
0
0
0
0
0
27,237
0
0
0
0
0
0
0
0
0
0
370,740
0
0
0
0
0
0
27,237
0
189,114
0
0
0
0
0
0
13,894
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
14,741
109,752
228,910
0
0
4,892
36,425
75,972
0
0
0
0
0
0
0
4,892
36,425
75,972
0
0
0
0
0
0
0
4,892
36,425
75,972
0
0
2,495
18,580
38,753
0
Report Date: Wednesday, February 17, 2016 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State: Colorado
Quarter Ended: 3/31/2017
Type of Eligible: Not Newly Disabled Person Non-Institutionalized
14
15
16
17A
17B
17C1
17D
18A
18A1
18A2
18A3
18A4
18A5
18B1
18B1a
18B1b
18B1c
18B1d
18B1e
18B2
18B2a
18B2b
18B2c
18B2d
18B2e
18C
18D
18E
19A
19B
19C
19D
22
23A
Abortions No. 0
EPSDT Screening Services
Rural Health Clinic Screening
Medicare Health Insurance Payments - Part A
Premiums
Medicare Health Insurance Payments - Part B
Premiums
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
Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin
Certified Community Behaviorial Health Clinic
Payments
Prepaid Ambulatory Health Plan
MCO PAHP - Evaluation and Management
MCO PAHP - Vaccine codes
MCO PAHP - Community First Choice
MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin
MCO PAHP - Certified Community Behaviorial
Health Clinic Payments
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
MCO PIHP - Certified Community Behaviorial
Health Clinic Payments
Medicaid Health Insurance Payments: Group
Health Plan Payments
Medicaid Health Insurance Payments:
Coinsurance And Deductibles
Medicaid Health Insurance Payments: Other
Home and Community-Based Services - Regular
Payment (Waiver)
Home and Community-Based Services - State
Plan 1915(i) Only Payment
Home and Community-Based Services - State
Plan 1915(j) Only Payment
Home and Community Based Services State
Plan 1915(k) Community First Choice
Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular Payment
Form CMS 64.9VIII
Family
Planning
FMAP
I.H.S. Services Services
0
0
0
354
45
0
13,110
1,666
0
Total
Computable
Opt. Breast or
Cervical
Cancer Srvcs
(ENH Rate)
0
0
0
0
0
0
Opt. Breast or
Cervical
Cancer Srvcs
(IHS Rate)
Other %
Federal Share
0
0.00
0
0
0.00
0
0
0.00
0
Total Comp
Resource Test Adjusted Total
Comp from Col
Applied to
Newly Col B X B NoT Newly
0
0
266
88
9,843
3,267
Total Comp
Enroll Cap
Applied to
Newly Col H X
0
0
0
Adjusted Total
Comp from Col
B minus
Resource Test
Col G minus
Enrollment
Cap COL I
0
88
3,267
Total Comp
Special
Circumstances
Applied to
Newly COL J
0
0
0
Adjusted Total
Comp from
COL B minus
Resource Test
COL G Minus
Enrollment
CAP COL I
minus Special
Circumstance Total Federal
COL K
Share
0
0
88
45
3,267
1,666
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
100.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
236,666
0
0
0
30,083
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0
0
0
0
177,692
0
0
0
58,974
0
0
0
0
0
0
0
58,974
0
0
0
0
0
0
0
58,974
0
0
0
30,083
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Report Date: Wednesday, February 17, 2016 - 12:00 AM
Department of Health and Human Services
Centers for Medicare & Medicaid Services
OMB No. 0938-1265
Expires 12/31/2017
Form CMS 64.9VIII - Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in This Quarter
State: Colorado
Quarter Ended: 3/31/2017
Type of Eligible: Not Newly Disabled Person Non-Institutionalized
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42
43
44
49
50
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
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 64.9VIII
Total
Computable
FMAP
0
Family
Planning
I.H.S. Services Services
0
0
Adjusted Total
Comp from
COL B minus
Resource Test
Adjusted Total
COL G Minus
Comp from Col
Enrollment
B minus
Total Comp
CAP COL I
Resource Test Special
Total Comp
Total Comp
Opt. Breast or Opt. Breast or
Col G minus
Resource Test Adjusted Total Enroll Cap
Circumstances minus Special
Cervical
Cervical
Circumstance Total Federal
Enrollment
Applied to
Applied to
Comp from Col Applied to
Cancer Srvcs Cancer Srvcs
Newly COL J COL K
Share
(IHS Rate)
Other %
Federal Share Newly Col B X B NoT Newly Newly Col H X Cap COL I
(ENH Rate)
0
0
0
0.00
0
0
0
0
0
0
0
0
0
0
43,510
53,853
0
157,376
0
0
0
0
0
0
0
0
5,531
6,845
0
20,004
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
32,668
40,434
0
118,160
0
0
0
0
0
0
0
0
10,842
13,419
0
39,216
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10,842
13,419
0
39,216
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10,842
13,419
0
39,216
0
0
0
0
0
0
0
0
5,531
6,845
0
20,004
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
358
6,108,418
0
0
45
776,436
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.00
0.00
0.00
0.00
0
0
0
0
0
0
269
4,586,290
0
0
89
1,522,128
0
0
0
0
0
0
89
1,522,128
0
0
0
0
0
0
89
1,522,128
0
0
45
776,436
Report Date: Wednesday, February 17, 2016 - 12:00 AM
| File Type | application/pdf |
| File Title | 64 9 VIII with new line items |
| Author | Christopher Kessler |
| File Modified | 2016-03-23 |
| File Created | 2016-03-23 |