CMS 64.9T Medical Assistance Expenditures by Type of Service For t

CMS 64.9T

State: New Hampshire
Agency: CMS

Medical Assistance Expenditures by Type of Service
For the Medical Assistance Program
Expenditures in this Quarter

Medical Assistance Payments
1A) Inpatient Hospital - Reg. Payments 1A
1B) Inpatient Hospital - DSH 1B
1C) Inpatient Hospital - Sup. Payments 1C
1D) Inpatient Hospital - GME Payments 1D
2A) Mental Health Facility Services - Reg. Payments 2A
2B) Mental Health Facility - DSH 2B
2C) Certified Community Behavioral Health Clinic
Payments 65.00%
4A) Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers 4A
4B) Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers 4B
4C) Intermediate Care Facility Services - Supplemental
Payments 4C
5A) Physician & Surgical Services - Reg. Payments 5A
5B) Physician & Surgical Services - Sup. Payments 5B
5C) Physician & Surgical Services - Evaluation and
Management 5C
5D) Physician & Surgical Services - Vaccine codes 5D
6A) Outpatient Hospital Services - Reg. Payments 6A
6B) Outpatient Hospital Services - Sup. Payments 6B
7) Prescribed Drugs 7
7A1) Drug Rebate Offset - National 7A1
7A2) Drug Rebate Offset - State Sidebar Agreement 7A2
7A3) MCO - National Agreement 7A3
7A4) MCO - State Sidebar Agreement 7A4
7A5) Increased ACA OFFSET - Fee for Service - 100% 7A5
7A6) Increased ACA OFFSET - MCO - 100% 7A6
8) Dental Services 8
9A) Other Practitioners Services - Reg. Payments 9A
9B) Other Practitioners Services - Sup. Payments 9B
10) Clinic Services 10
11) Laboratory/Radiological 11
12) Home Health Services 12
13) Sterilizations 13
14) Abortions 14
15) EPSDT Screening 15
16) Rural Health 16
17A) Medicare - Part A 17A
17B) Medicare - Part B 17B
17C1) 120% - 134% Of Poverty 17C1
17D) Coinsurance 17D
18A) Medicaid - MCO 18A
18A1) Medicaid MCO - Evaluation and Management
18A1
18A2) Medicaid MCO - Vaccine codes 18A2
18A3) Medicaid MCO - Community First Choice 18A3
18A4) Medicaid MCO - Preventive Services Grade A OR
B, ACIP Vaccines and their Admin 18A4
18A5) Medicaid MCO - Certified Comm Behavioral
Health Clinic Paym 65.00%

Quarter/Year: Qtr 2nd 2017
Quarter Ended: 3/31/2017

Total Computable
(A)
78,885
0
0
0
26,920
0

Federal Share
Medicaid and CHIP Medicaid FMAP
Applied against the 20% Limit
88%
50%
CHIP Amount
(B)
(C)
(D)
69,419
39,443
29,976
0
0
0
0
0
0
0
0
0
23,690
13,460
10,230
0
0
0

2,000

1,760

1,000

760

0

0

0

0

0

0

0

0

0
60,566
0

0
53,298
0

0
30,283
0

0
23,015
0

0
0
55,823
0
95,767
(58,931)
(5,614)
0
0

0
0
49,124
0
84,275
(51,859)
(4,940)
0
0

0
0
27,912
0
47,884
(29,466)
(2,807)
0
0

0
0
21,212
0
36,391
(22,393)
(2,133)
0
0

0
0
753,524
12,296
0
404,736
54
31,255
0
0
0
3,209
0
0
0
0
4,123,212

0
0
663,101
10,820
0
356,168
48
27,504
0
0
0
2,824
0
0
0
0
3,628,427

0
0
376,762
6,148
0
202,368
27
15,628
0
0
0
1,605
0
0
0
0
2,061,606

0
0
286,339
4,672
0
153,800
21
11,876
0
0
0
1,219
0
0
0
0
1,566,821

0
0
0

0
0
0

0
0
0

0
0
0

0

0

0

0

2,000

1,760

1,000

760

18B1b) MCO PAHP - Vaccine codes 18B1b
18B1c) MCO PAHP - Community First Choice 18B1c
18B1d) MCO PAHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin 18B1d
18B1e) MCO PAHP - Certified Comm Behavioral Health
Clinic Paym 65.00%
18B2b) MCO PIHP - Vaccine codes 18B2b
18B2c) MCO PIHP - Community First Choice 18B2c
18B2d) MCO PIHP - Preventive Services Grade A OR B,
ACIP Vaccines and their Admin 18B2d
18B2e) MCO PIHP - Certified Comm Behavioral Health
Clinic Paym 65.00%
18E) Medicaid - Other 18E
19A) Home & Community-Based Services - Reg. Pay.
(Waiv) 19A
19B) Home & Community-Based Services - St. Plan
1915(i) Only Pay. 19B
19C) Home & Community-Based Services - St. Plan
1915(j) Only Pay. 19C
19D) Home & Community Based Services State Plan
1915(k) Community First Choice 19D
22) All-Inclusive Care Elderly 22
23A) Personal Care Services - Reg. Payments 23A
23B) Personal Care Services - SDS 1915(j) 23B
24A) Targeted Case Management Services - Com. CaseMan. 24A
24B) Case Management - State Wide 24B
25) Primary Care Case Management 25
26) Hospice Benefits 26
27) Emergency Services for Undocumented Aliens 27
28) Federally-Qualified Health Center 28
29) Non-Emergency Medical Transportation 29
30) Physical Therapy 30
31) Occupational Therapy 31
32) Services for Speech, Hearing & Language 32
33) Prosthetic Devices, Dentures, Eyeglasses 33
34) Diagnostic Screening & Preventive Services 34
34A) Preventive Services Grade A OR B, ACIP Vaccines
and their Admin 34A
35) Nurse Mid-Wife 35
36) Emergency Hospital Services 36
37) Critical Access Hospitals 37
38) Nurse Practitioner Services 38
39) School Based Services 39
40) Rehabilitative Services (non-school-based) 40
41) Private Duty Nursing 41
42) Freestanding Birth Center 42
43) Health Home for Enrollees w Chronic Conditions 43
44) Tobacco Cessation for Preg Women 44
49) Other Care Services 49
50) Total 50

0
0

0
0

0
0

0
0

0

0

0

0

2,000
0
0

1,760
0
0

1,000
0
0

760
0
0

0

0

0

0

2,000
0

1,760
0

1,000
0

760
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

27,964
0
0
0
0
0
0
0
0
0
0
0

24,608
0
0
0
0
0
0
0
0
0
0
0

13,982
0
0
0
0
0
0
0
0
0
0
0

10,626
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
105,405
0
0
0
0
344,343
6,109,410

0
0
0
0
0
0
92,756
0
0
0
0
303,022
5,376,282

0
0
0
0
0
0
52,703
0
0
0
0
172,172
3,054,709

0
0
0
0
0
0
40,053
0
0
0
0
130,850
2,321,573
Remaining Balance: 49,418,810