Form CMS-64 Medical Assistance Expenditures by Type of Service For t

Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (CMS-10529)

64 Blank Forms

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

OMB: 0938-1265

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Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medicaid Assistance Expenditures
For the Medical Assistance Program
State:

Quarter Ended: 06/30/2017
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 allow able in accordance w ith 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 w ere available and used to match the state’s allow able expenditures included in this report,
and such state and/or local funds w ere in accordance w ith 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 w as submitted after January 2, 2001, and that has not been approved by the Secretary effective for the Quarter Ended
indicated above.
6. The information show n above and on the Form CMS-64 Summary Sheet and the Supporting Schedules is correct to the best of my
know ledge and belief.
Date:

Signature:

Title:

User Performing Certification:
Footnotes:

Form CMS 64 Certification

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medicaid Statement of Expenditures
For the Medical Assistance
Program Summary Sheet

Total
Computable
(A)

Quarter Ended:

Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

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 ClaimsFor 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

Quarter Ended:

Medical Assistance Payments
Federal Share
Medicaid
ARRA
BIPP
(B)
(C)
(D)

State and Local
Administration
Total
(E)

Total Computable Federal Share

(F)

(G)

Net Expenditures Reported In ThisPeriod (Sum of Items 6, 7 and 8
Less 9 and 10)

Form CMS 64 Summary

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Payments

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

Other & Prompt Pay
Other %
(Oth)

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9Base

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Payments

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Prompt Pay
(PP)

Total
Federal
Share

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

Other & Prompt Pay
Other %
(Oth)

MCO - State Sidebar Agreement

9A

10

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

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

Form CMS 64.9Base

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Payments

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9Base

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Payments

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9Base

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Payments

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9Base

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

Other & Prompt Pay
Other %
(Oth)

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9 Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Prompt Pay
(PP)

Total
Federal
Share

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

Other & Prompt Pay
Other %
(Oth)

MCO - State Sidebar Agreement

9A

10

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

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

Form CMS 64.9 Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9 Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9 Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9 Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
Other & Prompt Pay

1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9P

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
Other & Prompt Pay

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Form CMS 64.9P

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
Other & Prompt Pay

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Form CMS 64.9P

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
Other & Prompt Pay

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9P

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
Other & Prompt Pay

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9P

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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 - National Agreement

7A2

Drug Rebate - State Sidebar Agreement

Form CMS 64.9P Waiver

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

13

Sterilizations

14

Abortions

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Form CMS 64.9P Waiver

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Form CMS 64.9P Waiver

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9P Waiver

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9P Waiver

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Overpayment Adjustment
State:

Quarter Ended:
Total

Overpayment Activity

Federal Share

Computable
(A)

1 Ov erpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Y ear Time
Limit

Total

FY

FY

FY

FY

(B)

(C)

(D)

(E)

Federal
(F)

VIII:

VIII:

VIII:

VIII:

VIII:

0

VIII:

VIII:

VIII:

VIII:

VIII:

0

VIII:

VIII:

VIII:

VIII:

VIII:

0

VIII:

VIII:

VIII:

VIII:

VIII:

0

VIII:

VIII:

VIII:

VIII:

VIII:

0

2 Decreasing Adjustments To Amounts
Prev iously Reported On Line 1

3 Subtotal

4 Prev iously Reported Overpayments
To Prov iders Certified This Quarter
As Bankrupt Or Out Of Business

5 Total Ov erpayment Adjustments This
Quarter

Form CMS 64.9O

Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017
Fraud, Waste & Abuse Amounts Overpayments - Federal Credit Due
From Medicaid Program Integrity Activities

State:

Medical Assistance Payments

Total
Computable
(A)

Medicaid
(Non-VIII Group)
Federal Share

(B)

Medicaid VIII
Group Federal
Share
(C)

ARRA Federal
Share

BIPP Federal
Share

Federal Share

(D)

(E)

(F)

*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.
Wednesday, September 13, 2017 - 09:22 AM
Form CMS 64.9OFWA

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Overpayment Adjustment
State:

Quarter Ended:
Federal Share

Total
PERM Activity

Computable
(A)

1 Ov erpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Y ear Time
Limit

Total

PERM-identified Overpayments
FY

FY

FY

FY

(B)

(C)

(D)

(E)

Federal
(F)

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

VIII:

2 Decreasing Adjustments To Amounts
Prev iously Reported On Line 1

3 Subtotal

4 Prev iously Reported Overpayments
To Prov iders Certified This Quarter
As Bankrupt Or Out Of Business

5 Total Ov erpayment Adjustments This
Quarter

Form CMS 64.9O PERM

Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Overpayment Adjustment
State:

Quarter Ended:
Federal Share

Total
RAC Activity

Total

RAC-identified Overpayments

Computable

FY

(A)

FY

(B)

1 Ov erpayments Not Collected Or
Adjusted But Refunded Because Of
The Expiration Of The 1 Y ear Time
Limit

VIII:

2 Decreasing Adjustments To Amounts
Prev iously Reported On Line 1

VIII:

3 Subtotal

VIII:

FY

(C)
VIII:

(D)
VIII:

Federal

FY
(E)

(F)

VIII:
VIII:

VIII:

VIII:

VIII:
VIII:

VIII:

VIII:

VIII:
VIII:

4 Prev iously Reported Overpayments
To Prov iders Certified This Quarter
As Bankrupt Or Out Of Business

VIII:

5 Total Ov erpayment Adjustments This
Quarter

VIII:

Form CMS 64.9O RAC

VIII:

VIII:

VIII:
VIII:

VIII:

VIII:

VIII:
VIII:

Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017
Third Party Liability Collections And Cost Avoidance
Quarter Ended:

State:
Total Computable

Medicaid
(Non-VIII Group)
Federal Share

Medicaid VIII
Group Federal
Share

ARRA Federal
Share

BIPP Federal
Share

Federal Share

(A)

(B)

(C)

(D)

(E)

(F)

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
Collections To Reimburse State Title XIX Medical
2. Net
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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

Other & Prompt Pay
Other %
(Oth)

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

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

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Prompt Pay
(PP)

Total
Federal
Share

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

Other & Prompt Pay
Other %
(Oth)

MCO - State Sidebar Agreement

9A

10

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

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

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share matched at 100%
Other & Prompt Pay

1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(C)

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share matched at 100%
Other & Prompt Pay

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(C)

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share matched at 100%
Other & Prompt Pay

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(C)

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share matched at 100%
Other & Prompt Pay

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(C)

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share matched at 100%
Other & Prompt Pay

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Total
Comp.

FMAP

(A)

(B)

IHS
Facility
Services
100%

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(C)

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

All columns matched at 100%, State Share applied to 200K

Form CMS 64.9 200K P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

Form CMS 64.10Base

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share
Total
Computable
(A)

49

Other Financial Participation

50

Total

Form CMS 64.10Base

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

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 Waiver

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Quarter Ended:
Federal Share
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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

Form CMS 64.10 Waiver

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Expenditures In This Quarter
State:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Quarter Ended:
Federal Share
Total
Computable
(A)

49

Other Financial Participation

50

Total

Form CMS 64.10 Waiver

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
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%)

16

TANF Secondary (75%)

17

External Review

18

Enrollment Brokers

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Total
Computable
(A)
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

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Total
Computable
(A)
28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

49

Other Financial Participation

50

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Waiver Type:
Waiver Nam e:
Waiver Num ber:
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%)

16

TANF Secondary (75%)

17

External Review

18

Enrollment Brokers

Form CMS 64.10P Waiver

Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Waiver Type:
Waiver Nam e:
Waiver Num ber:
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

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

Form CMS 64.10P Waiver

Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Waiver Type:
Waiver Nam e:
Waiver Num ber:
28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

49

Other Financial Participation

50

Total

Form CMS 64.10P Waiver

Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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
Quarter Ended:

State:
Plan Name
(A)

Receipts
(B)

Donations
1.

Donations - Medicaid

1.A.

Donations - CHIP

2.
2.A.
Taxes

Donations- Outstationed Eligibility Workers - Medicaid
Donations - Outstationed Eligibility Workers - CHIP

3.
Fees

Taxes

4.
Fees
Assessments
5.
Totals

Assessments

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 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

FFY 2014 (10/01/2013 - 09/30/2014)
1

FFY 2014 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 2014 Allotment

10

Excess Expenditures

Form CMS 64.9D

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 2015 (10/01/2014 - 09/30/2015)
1

FFY 2015 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 2015 Allotment

10

Excess Expenditures

FFY 2016 (10/01/2015 - 09/30/2016)
1

FFY 2016 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 2016 Allotment

10

Excess Expenditures

Form CMS 64.9D

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 2017 (10/01/2016 - 09/30/2017)
1

FFY 2017 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 2017 Allotment

10

Excess Expenditures

Form CMS 64.9D

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017
Medicaid Drug Rebate Schedule

State:

Quarter Ended:
Total Computable

Drug Rebate

Qtr. Ending Qtr. Ending Qtr. Ending Qtr. Ending Qtr. Ending
06/30/2017

(A)
1

Balance Of The Beginning Of The Quarter

2

Adjustments To Prev iously Reported Rebates From
Drug Labelers Included In Line 1

3

Rebates Inv oiced In This Quarter

4

Subtotal

5

Rebates Reported On This Expenditure Report

6

Balance As Of The End Of The Quarter

03/31/2017

(B)

12/31/2016

(C)

09/30/2016

(D)

Total

06/30/2016
and Prior

(E)

(F)

FOOTNOTE:

Form CMS 64.9R

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Program Expenditure Report
Other Narrative Explainations

Quarter Ended:

Narrative

Form CMS 64 Narrative

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Pov erty Lev el - Gross
Premiums Paid

1B

Premiums Up To 150% of Pov erty Level: Cost
Sharing Of f sets

1C

Premiums Ov er 150% of Pov erty Lev el - Gross
Premiums Paid

1D

Premiums Ov er 150% of Pov erty Lev el: Cost
Sharing Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments
Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH
Adjustment Pay ments

3B

Certif ied Community Behav ior Health Clinic
Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

12

Clinic Serv ices

Form CMS 64.21

FMAP

(B)

IHS Facility
Services
100 %
(C)

Fam. Plan
Services Prompt Pay Total Federal
Share
90%
(D)
(E)
(F)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:

Quarter Ended:
Federal Share

Type of Eligible:

Total
Computable
(A)
13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular
Pay ment (WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Total

Form CMS 64.21

FMAP

(B)

IHS Facility
Services
100 %
(C)

Fam. Plan
Services Prompt Pay Total Federal
Share
90%
(D)
(E)
(F)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

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
(A)
1A

Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid

1B

Premiums Up To 150% Of Poverty Level - Cost Sharing
Of f set

1C

Premiums Over 150% Of Poverty Level - Gross Premiums
Paid

1D

Premiums Over 150% Of Poverty Level - Cost Sharing
Of f set

2

Inpatient Hospital Services - Regular Payments

2A

Inpatient Hospital Services - DSH Adjustments Payments

3

Inpatient Mental Health Facility Services - Regular
Pay ments

3A

Inpatient Mental Health Facility Services - DSH
Adjustments Payments

3B

Certif ied Community Behavior Health Clinic Payments

4

Nursing Care Services

5

Phy sician 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 f or Service - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Services

Form CMS 64.21P

Incr. FMAP

(B)

I.H.S Facility
Services
100%

(C)

Fam. Plan
Prompt Pay
Services
90%

(D)

(E)

Total
Federal
Share

Deferral or
C.I.N.
Number

(F)

(G)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

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
(A)
12

Clinic Serv ices

13

Therapy Serv ices

14

Laboratory And Radiological services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

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 Serv ices

28

Total

Form CMS 64.21P

Incr. FMAP

(B)

I.H.S Facility
Services
100%

(C)

Fam. Plan
Prompt Pay
Services
90%

(D)

(E)

Total
Federal
Share

Deferral or
C.I.N.
Number

(F)

(G)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:

Quarter Ended:
Federal Share

Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Total
Computable
(A)

1A

Premiums: Up To 150% of Pov erty Lev el - Gross
Premiums Paid

1B

Premiums Up To 150% of Pov erty Level: Cost
Sharing Of f sets

1C

Premiums Ov er 150% of Pov erty Lev el - Gross
Premiums Paid

1D

Premiums Ov er 150% of Pov erty Lev el: Cost
Sharing Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments
Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH
Adjustment Pay ments

3B

Certif ied Community Behav ior Health Clinic
Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

12

Clinic Serv ices

Form CMS 64.21 Waiver

FMAP

(B)

IHS Facility
Services
100 %
(C)

Fam. Plan
Services Prompt Pay Total Federal
Share
90%
(D)
(E)
(F)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:

Quarter Ended:
Federal Share

Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Total
Computable
(A)

13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular
Pay ment (WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Total

Form CMS 64.21 Waiver

FMAP

(B)

IHS Facility
Services
100 %
(C)

Fam. Plan
Services Prompt Pay Total Federal
Share
90%
(D)
(E)
(F)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

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 Nam e:
Waiver Num ber:

Federal Share
FMAP

Total
Computable
(A)

1A

Premiums Up To 150% Of Poverty Level - Gross
Premiums Paid

1B

Premiums Up To 150% Of Poverty Level - Cost Sharing
Of f set

1C

Premiums Over 150% Of Poverty Level - Gross Premiums
Paid

1D

Premiums Over 150% Of Poverty Level - Cost Sharing
Of f set

2

Inpatient Hospital Services - Regular Payments

2A

Inpatient Hospital Services - DSH Adjustments Payments

3

Inpatient Mental Health Facility Services - Regular
Pay ments

3A

Inpatient Mental Health Facility Services - DSH
Adjustments Payments

3B

Certif ied Community Behavior Health Clinic Payments

4

Nursing Care Services

5

Phy sician 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 f or Service - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Services

Form CMS 64.21P Waiver

Incr. FMAP

(B)

I.H.S Facility
Services
100%

(C)

Fam. Plan
Prompt Pay
Services
90%

(D)

(E)

Total
Federal
Share

Deferral or
C.I.N.
Number

(F)

(G)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

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 Nam e:
Waiver Num ber:

Federal Share
FMAP

Total
Computable
(A)

12

Clinic Serv ices

13

Therapy Serv ices

14

Laboratory And Radiological services

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

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 Serv ices

28

Total

Form CMS 64.21P Waiver

Incr. FMAP

(B)

I.H.S Facility
Services
100%

(C)

Fam. Plan
Prompt Pay
Services
90%

(D)

(E)

Total
Federal
Share

Deferral or
C.I.N.
Number

(F)

(G)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:

Quarter Ended:
Federal Share

Type of Eligible:

CHIP

Total
Computable
(A)
1A

Premiums Up To 150% Of Pov erty Lev el - Gross Premiums
Paid

1B

Premiums Up To 150% Of Pov erty Lev el - Cost Sharing
Of f sets

1C

Premiums Ov er 150% Of Pov erty Lev el - Gross Premiums
Paid

1D

Premiums Ov er 150% Of Pov erty Lev el - Cost Sharing
Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH Adjustment
Pay ments

3B

Certif ied Community Behav ior Health Clinic Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

12

Clinic Serv ices

Form CMS 64.21U

FMAP

(B)

(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:

Quarter Ended:
Federal Share

Type of Eligible:

CHIP

Total
Computable
(A)
13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular Pay ment
(WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Total

Form CMS 64.21U

FMAP

(B)

(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Quarter Ended:
Federal Share
CHIP

Total
Computable
(A)

1A

Premiums Up To 150% Of Pov erty Lev el - Gross Premiums
Paid

1B

Premiums Up To 150% Of Pov erty Lev el - Cost Sharing
Of f sets

1C

Premiums Ov er 150% Of Pov erty Lev el - Gross Premiums
Paid

1D

Premiums Ov er 150% Of Pov erty Lev el - Cost Sharing
Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH Adjustment
Pay ments

3B

Certif ied Community Behav ior Health Clinic Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

12

Clinic Serv ices

Form CMS 64.21U Waiver

FMAP

(B)

(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program
Expenditure Categories
State:
Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Quarter Ended:
Federal Share
CHIP

Total
Computable
(A)

13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular Pay ment
(WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Total

Form CMS 64.21U Waiver

FMAP

(B)

(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Federal Share

Type of Eligible:

1A

Premiums Up To 150% Of Pov erty Lev el - Gross Premiums
Paid

1B

Premiums Up To 150% Of Pov erty Lev el - Cost Sharing
Of f sets

1C

Premiums Ov er 150% Of Pov erty Lev el - Gross Premiums
Paid

1D

Premiums Ov er 150% Of Pov erty Lev el - Cost Sharing
Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH Adjustments
Pay ments

3B

Certif ied Community Behav ior Health Clinic Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

Form CMS 64.21UP

FMAP

Total
Computable

Incr FMAP

(A)

(B)

CHIP

Total
Federal
Share

Deferral
or
C.I.N.
Number

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Federal Share

Type of Eligible:

12

Clinic Serv ices

13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular Pay ment
(WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Balance

27

Collections

28

Total

Form CMS 64.21UP

FMAP

Total
Computable

Incr FMAP

(A)

(B)

CHIP

Total
Federal
Share

Deferral
or
C.I.N.
Number

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Federal Share

Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:
1A

Premiums Up To 150% Of Pov erty Lev el - Gross Premiums
Paid

1B

Premiums Up To 150% Of Pov erty Lev el - Cost Sharing
Of f sets

1C

Premiums Ov er 150% Of Pov erty Lev el - Gross Premiums
Paid

1D

Premiums Ov er 150% Of Pov erty Lev el - Cost Sharing
Of f sets

2

Inpatient Hospital Serv ices - Regular Pay ments

2A

Inpatient Hospital Serv ices - DSH Adjustments Pay ments

3

Inpatient Mental Health Facility Serv ices - Regular
Pay ments

3A

Inpatient Mental Health Facility Serv ices - DSH Adjustments
Pay ments

3B

Certif ied Community Behav ior Health Clinic Pay ments

4

Nursing Care Serv ices

5

Phy sician And Surgical Serv ices

6

Outpatient Hospital Serv ices

7

Outpatient Mental Health Facility Serv ices

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 f or Serv ice - 100%

8A6

Increased ACA OFFSET - MCO - 100%

9

Dental Serv ices

10

Vision Serv ices

11

Other Practitioners' Serv ices

Form CMS 64.21UP Waiver

FMAP

Total
Computable

Incr FMAP

(A)

(B)

CHIP

Total
Federal
Share

Deferral
or
C.I.N.
Number

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
By Children's Health Insurance Program Expenditure Categories
Prior Period Expenditures
Quarter Ended:
Qtr/Fiscal Year:
Line #
Federal Share

Type of Eligible:
Waiver Type:
Waiver Nam e:
Waiver Num ber:
12

Clinic Serv ices

13

Therapy Serv ices

14

Laboratory And Radiological Serv ices

15

Durable And Disposable Medical Equipment

16

Family Planning

17

Abortions

18

Screening Serv ices

19

Home Health

20

Medicare Pay ments

21

Home And Community -Based Serv ices

21A

Home and Community -Based Serv ices - Regular Pay ment
(WAIVER)

22

Hospice

23

Medical Transportation

24

Case Management

25

Other Serv ices

26

Balance

27

Collections

28

Total

Form CMS 64.21UP Waiver

FMAP

Total
Computable

Incr FMAP

(A)

(B)

CHIP

Total
Federal
Share

Deferral
or
C.I.N.
Number

(C)

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Section C
Expenditures Reported for Period
By Form Num ber

Quarter Ended:
Medicaid Assist. Payments
Total Comp.
(A)

Fed. Share
(B)

Medicaid/CHIP
Total Comp.
(C)

Fed. Share
(D)

State and Local Admin.
20% Fed Shr Total Comp. Federal Share
(E)
(F)
(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-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
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-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
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-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS-64.21P
From Form CMS-64.21UP

9. Collections

Form CMS 64 F

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medical Assistance Expenditures
For the Medical Assistance Program
Summary Sheet
State:
Section C
Expenditures Reported for Period
By Form Num ber

Quarter Ended:
Medicaid Assist. Payments
Total Comp.
(A)

Fed. Share
(B)

State and Local Admin.

Medicaid/CHIP
Total Comp.
(C)

Fed. Share
(D)

20% Fed Shr Total Comp. Federal Share
(E)
(F)
(G)

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-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
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-64.9VIII NEWLY
From Form CMS-64.9VIII NOT NEWLY
From Form CMS 64.21P
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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9I

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9I

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9I

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9I

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9I

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9PI

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Form CMS 64.9PI

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Form CMS 64.9PI

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9PI

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9PI

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

Form CMS 64.10I

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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)

49

Other Financial Participation

50

Total

Form CMS 64.10I

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Administration
Special Issue Reporting Program :

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%)

16

TANF Secondary (75%)

17

External Review

18

Enrollment Brokers

Form CMS 64.10PI

Federal Share
Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Administration
Special Issue Reporting Program :

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

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

Form CMS 64.10PI

Federal Share
Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration
For the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Administration
Special Issue Reporting Program :

28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

49

Other Financial Participation

50

Total

Form CMS 64.10PI

Federal Share
Total
Computable
(A)

FFP
Rate

Federal
Share
(B)

Federal
Share

0.0%

(C)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents

Total Computable
Medicaid and CHIP Medicaid FMAP

Applied Against
the 20% Limit

FMAP
CHIP

(A)
1A

Inpatient Hospital Serv ices - Regular Pay ments

1B

Inpatient Hospital Serv ice - DSH Adjustment
Pay ments

1C

Inpatient Hospital Serv ices - Supplemental Pay ments

1D

Inpatient Hospital Serv ices - GME Pay ments

2A

Mental Health Facility Serv ices - Regular Pay ments

2B

Mental Health Facility Serv ices - DSH Adjustment
Pay ments

2C

Certif ied Community Behav ior Health Clinic
Pay ments

3A

Nursing Facility Serv ices - Regular Pay ments

3B

Nursing Facility Serv ices - Supplemental Pay ments

4A

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Public Prov iders

4B

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Priv ate Prov iders

4C

Intermediate Care Facility Serv ices - Supplemental
Pay ments

5A

Phy sician and Surgical Serv ices - Regular Pay ments

5B

Phy sician and Surgical Serv ices - Supplemental
Pay ments

5C

Phy sician & Surgical Serv ices - Ev aluation and
Management

5D

Phy sician & Surgical Serv ices - Vaccine codes

6A

Outpatient Hospital Serv ices - Regular Pay ments

6B

Outpatient Hospital Serv ices - Supplemental
Pay ments

7

Prescribed Drugs

7A1

Drug Rebate Of f set - National Agreement

7A2

Drug Rebate Of f set - State Sidebar Agreement

7A3

MCO - National Agreement

Form CMS 64.9T

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents

Total Computable
Medicaid and CHIP Medicaid FMAP

Applied Against
the 20% Limit

FMAP
CHIP

(A)
7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee f or Serv ice - 100%

7A6

Increased ACA OFFSET - MCO - 100%

8

Dental Serv ices

9A

Other Practitioners Serv ices - Regular Pay ments

9B

Other Practitioners Serv ices - Supplemental
Pay ments

10

Clinic Serv ices

11

Laboratory And Radiological Serv ices

12

Home Health Serv ices

13

Sterilizations

14

Abortions No.

15

EPSDT Screening Serv ices

16

Rural Health Clinic Screening

17A

Medicare Health Insurance Pay ments - Part A
Premiums

17B

Medicare Health Insurance Pay ments - Part B
Premiums

17C1

120% - 134% Of Pov erty

17D

Coinsurance And Deductibles

18A

Medicaid Health Insurance Pay ments: Managed Care
Organizations (MCO)

18A1

Medicaid MCO - Ev aluation and Management

18A2

Medicaid MCO - Vaccine codes

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

Form CMS 64.9T

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents

Total Computable
Medicaid and CHIP Medicaid FMAP

Applied Against
the 20% Limit

FMAP
CHIP

(A)
18A5

Medicaid MCO - Certif ied Community Behav ior
Health Clinic Pay ments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Ev aluation and Management

18B1
b

MCO PAHP - Vaccine codes

18B1
c

MCO PAHP - Community First Choice

18B1
d

MCO PAHP - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

18B1
e

Medicaid PAHP - Certif ied Community Behav ior
Health Clinic Pay ments

18B2

Prepaid Inpatient Health Plan

18B2
a

MCO PIHP - Ev aluation and Management

18B2
b

MCO PIHP - Vaccine codes

18B2
c

MCO PIHP - Community First Choice

18B2
d

MCO PIHP - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

18B2
e

Medicaid PIHP - Certif ied Community Behav ior
Health Clinic Pay ments

18C

Medicaid Health Insurance Pay ments: Group Health
Plan Pay ments

18D

Medicaid Health Insurance Pay ments: Coinsurance
And Deductibles

18E

Medicaid Health Insurance Pay ments: Other

19A

Home and Community -Based Serv ices - Regular
Pay ment (Waiv er)

19B

Home and Community -Based Serv ices - State Plan
1915(i) Only Pay ment

19C

Home and Community -Based Serv ices - State Plan
1915(j) Only Pay ment

19D

Home and Community Based Serv ices State Plan
1915(k) Community First Choice

22

Programs Of All-Inclusiv e Care Elderly

Form CMS 64.9T

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents

Total Computable
Medicaid and CHIP Medicaid FMAP

Applied Against
the 20% Limit

FMAP
CHIP

(A)
23A

Personal Care Serv ices - Regular Pay ment

23B

Personal Care Serv ices - SDS 1915(j)

24A

Targeted Case Management Serv ices - Community
Case-Management

24B

Case Management - State Wide

25

Primary Care Case Management Serv ices

26

Hospice Benef its

27

Emergency Serv ices f or Undocumented Aliens

28

Federally -Qualif ied Health Center

29

Non-Emergency Medical Transportation

30

Phy sical Therapy

31

Occupational Therapy

32

Serv ices f or Speech, Hearing and Language

33

Prosthetic Dev ices, Dentures, Ey eglasses

34

Diagnostic Screening & Prev entiv e Serv ices

34A

Prev entiv e Serv ices Grade A OR B, ACIP Vaccines
and their Admin

35

Nurse Mid-Wif e

36

Emergency Hospital Serv ices

37

Critical Access Hospitals

38

Nurse Practitioner Serv ices

39

School Based Serv ices

40

Rehabilitativ e Serv ices (non-school-based)

41

Priv ate Duty Nursing

Form CMS 64.9T

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents

Total Computable
Medicaid and CHIP Medicaid FMAP

Applied Against
the 20% Limit

FMAP
CHIP

(A)
42

Freestanding Birth Center

43

Health Home f or Enrollees w Chronic Conditions

44

Tobacco Cessation f or Preg Women

49

Other Care Serv ices

50

Total

Form CMS 64.9T

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents

Federal Share

Total
Computable
Medicaid and CHIP

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
1A

Inpatient Hospital Serv ices - Regular
Pay ments

1B

Inpatient Hospital Serv ice - DSH Adjustment
Pay ments

1C

Inpatient Hospital Serv ices - Supplemental
Pay ments

1D

Inpatient Hospital Serv ices - GME Pay ments

2A

Mental Health Facility Serv ices - Regular
Pay ments

2B

Mental Health Facility Serv ices - DSH
Adjustment Pay ments

2C

Certif ied Community Behav ior Health Clinic
Pay ments

3A

Nursing Facility Serv ices - Regular Pay ments

3B

Nursing Facility Serv ices - Supplemental
Pay ments

4A

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Public Prov iders

4B

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Priv ate Prov iders

4C

Intermediate Care Facility Serv ices Supplemental Pay ments

5A

Phy sician and Surgical Serv ices - Regular
Pay ments

5B

Phy sician and Surgical Serv ices Supplemental Pay ments

5C

Phy sician & Surgical Serv ices - Ev aluation
and Management

5D

Phy sician & Surgical Serv ices - Vaccine
codes

6A

Outpatient Hospital Serv ices - Regular
Pay ments

6B

Outpatient Hospital Serv ices - Supplemental
Pay ments

7

Prescribed Drugs

7A1

Drug Rebate Of f set - National Agreement

7A2

Drug Rebate Of f set - State Sidebar
Agreement

7A3

MCO - National Agreement

Form CMS 64.9TP

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents

Federal Share

Total
Computable
Medicaid and CHIP

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee f or Serv ice 100%

7A6

Increased ACA OFFSET - MCO - 100%

8

Dental Serv ices

9A

Other Practitioners Serv ices - Regular
Pay ments

9B

Other Practitioners Serv ices - Supplemental
Pay ments

10

Clinic Serv ices

11

Laboratory And Radiological Serv ices

12

Home Health Serv ices

13

Sterilizations

14

Abortions No.

15

EPSDT Screening Serv ices

16

Rural Health Clinic Screening

17A

Medicare Health Insurance Pay ments - Part A
Premiums

17B

Medicare Health Insurance Pay ments - Part
B Premiums

17C1

120% - 134% Of Pov erty

17D

Coinsurance And Deductibles

18A

Medicaid Health Insurance Pay ments:
Managed Care Organizations (MCO)

18A1

Medicaid MCO - Ev aluation and Management

18A2

Medicaid MCO - Vaccine codes

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Prev entiv e Serv ices Grade A
OR B, ACIP Vaccines and their Admin

Form CMS 64.9TP

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents

Federal Share

Total
Computable
Medicaid and CHIP

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
18A5

Medicaid MCO - Certif ied Community
Behav ior Health Clinic Pay ments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Ev aluation and Management

18B1
b

MCO PAHP - Vaccine codes

18B1
c

MCO PAHP - Community First Choice

18B1
d

MCO PAHP - Prev entiv e Serv ices Grade A
OR B, ACIP Vaccines and their Admin

18B1
e

Medicaid PAHP - Certif ied Community
Behav ior Health Clinic Pay ments

18B2

Prepaid Inpatient Health Plan

18B2
a

MCO PIHP - Ev aluation and Management

18B2
b

MCO PIHP - Vaccine codes

18B2
c

MCO PIHP - Community First Choice

18B2
d

MCO PIHP - Prev entiv e Serv ices Grade A OR
B, ACIP Vaccines and their Admin

18B2
e

Medicaid PIHP - Certif ied Community
Behav ior Health Clinic Pay ments

18C

Medicaid Health Insurance Pay ments: Group
Health Plan Pay ments

18D

Medicaid Health Insurance Pay ments:
Coinsurance And Deductibles

18E

Medicaid Health Insurance Pay ments: Other

19A

Home and Community -Based Serv ices Regular Pay ment (Waiv er)

19B

Home and Community -Based Serv ices State Plan 1915(i) Only Pay ment

19C

Home and Community -Based Serv ices State Plan 1915(j) Only Pay ment

19D

Home and Community Based Serv ices State
Plan 1915(k) Community First Choice

22

Programs Of All-Inclusiv e Care Elderly

23A

Personal Care Serv ices - Regular Pay ment

Form CMS 64.9TP

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents

Federal Share

Total
Computable
Medicaid and CHIP

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
23B

Personal Care Serv ices - SDS 1915(j)

24A

Targeted Case Management Serv ices Community Case-Management

24B

Case Management - State Wide

25

Primary Care Case Management Serv ices

26

Hospice Benef its

27

Emergency Serv ices f or Undocumented
Aliens

28

Federally -Qualif ied Health Center

29

Non-Emergency Medical Transportation

30

Phy sical Therapy

31

Occupational Therapy

32

Serv ices f or Speech, Hearing and Language

33

Prosthetic Dev ices, Dentures, Ey eglasses

34

Diagnostic Screening & Prev entiv e Serv ices

34A

Prev entiv e Serv ices Grade A OR B, ACIP
Vaccines and their Admin

35

Nurse Mid-Wif e

36

Emergency Hospital Serv ices

37

Critical Access Hospitals

38

Nurse Practitioner Serv ices

39

School Based Serv ices

40

Rehabilitativ e Serv ices (non-school-based)

41

Priv ate Duty Nursing

42

Freestanding Birth Center

Form CMS 64.9TP

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents

Federal Share

Total
Computable
Medicaid and CHIP

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
43

Health Home f or Enrollees w Chronic
Conditions

44

Tobacco Cessation f or Preg Women

49

Other Care Serv ices

50

Total

Form CMS 64.9TP

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents
Waiver Type:

Medicaid and CHIP

Waiver Nam e:
Waiver Num ber:

Inpatient Hospital Serv ices - Regular
Pay ments

1B

Inpatient Hospital Serv ice - DSH Adjustment
Pay ments

1C

Inpatient Hospital Serv ices - Supplemental
Pay ments

1D

Inpatient Hospital Serv ices - GME Pay ments

2A

Mental Health Facility Serv ices - Regular
Pay ments

2B

Mental Health Facility Serv ices - DSH
Adjustment Pay ments

2C

Certif ied Community Behav ior Health Clinic
Pay ments

3A

Nursing Facility Serv ices - Regular Pay ments

3B

Nursing Facility Serv ices - Supplemental
Pay ments

4A

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Public Prov iders

4B

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Priv ate Prov iders

4C

Intermediate Care Facility Serv ices Supplemental Pay ments

5A

Phy sician and Surgical Serv ices - Regular
Pay ments

5B

Phy sician and Surgical Serv ices Supplemental Pay ments

5C

Phy sician & Surgical Serv ices - Ev aluation
and Management

5D

Phy sician & Surgical Serv ices - Vaccine
codes

6A

Outpatient Hospital Serv ices - Regular
Pay ments

6B

Outpatient Hospital Serv ices - Supplemental
Pay ments

7

Prescribed Drugs

7A1

Drug Rebate Of f set - National Agreement

7A2

Drug Rebate Of f set - State Sidebar
Agreement

7A3

MCO - National Agreement

Form CMS 64.9TP Waiver

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
1A

Federal Share

Total
Computable

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents
Waiver Type:

Medicaid and CHIP

Waiver Nam e:
Waiver Num ber:

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee f or Serv ice 100%

7A6

Increased ACA OFFSET - MCO - 100%

8

Dental Serv ices

9A

Other Practitioners Serv ices - Regular
Pay ments

9B

Other Practitioners Serv ices - Supplemental
Pay ments

10

Clinic Serv ices

11

Laboratory And Radiological Serv ices

12

Home Health Serv ices

13

Sterilizations

14

Abortions No.

15

EPSDT Screening Serv ices

16

Rural Health Clinic Screening

17A

Medicare Health Insurance Pay ments - Part A
Premiums

17B

Medicare Health Insurance Pay ments - Part
B Premiums

17C1

120% - 134% Of Pov erty

17D

Coinsurance And Deductibles

18A

Medicaid Health Insurance Pay ments:
Managed Care Organizations (MCO)

18A1

Medicaid MCO - Ev aluation and Management

18A2

Medicaid MCO - Vaccine codes

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Prev entiv e Serv ices Grade A
OR B, ACIP Vaccines and their Admin

Form CMS 64.9TP Waiver

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
7A4

Federal Share

Total
Computable

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents
Waiver Type:

Medicaid and CHIP

Waiver Nam e:
Waiver Num ber:

Medicaid MCO - Certif ied Community
Behav ior Health Clinic Pay ments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Ev aluation and Management

18B1
b

MCO PAHP - Vaccine codes

18B1
c

MCO PAHP - Community First Choice

18B1
d

MCO PAHP - Prev entiv e Serv ices Grade A
OR B, ACIP Vaccines and their Admin

18B1
e

Medicaid PAHP - Certif ied Community
Behav ior Health Clinic Pay ments

18B2

Prepaid Inpatient Health Plan

18B2
a

MCO PIHP - Ev aluation and Management

18B2
b

MCO PIHP - Vaccine codes

18B2
c

MCO PIHP - Community First Choice

18B2
d

MCO PIHP - Prev entiv e Serv ices Grade A OR
B, ACIP Vaccines and their Admin

18B2
e

Medicaid PIHP - Certif ied Community
Behav ior Health Clinic Pay ments

18C

Medicaid Health Insurance Pay ments: Group
Health Plan Pay ments

18D

Medicaid Health Insurance Pay ments:
Coinsurance And Deductibles

18E

Medicaid Health Insurance Pay ments: Other

19A

Home and Community -Based Serv ices Regular Pay ment (Waiv er)

19B

Home and Community -Based Serv ices State Plan 1915(i) Only Pay ment

19C

Home and Community -Based Serv ices State Plan 1915(j) Only Pay ment

19D

Home and Community Based Serv ices State
Plan 1915(k) Community First Choice

22

Programs Of All-Inclusiv e Care Elderly

23A

Personal Care Serv ices - Regular Pay ment

Form CMS 64.9TP Waiver

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
18A5

Federal Share

Total
Computable

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Fiscal Year:

State:
Line #
Medical Assistance Paym ents
Waiver Type:

Medicaid and CHIP

Waiver Nam e:
Waiver Num ber:

Personal Care Serv ices - SDS 1915(j)

24A

Targeted Case Management Serv ices Community Case-Management

24B

Case Management - State Wide

25

Primary Care Case Management Serv ices

26

Hospice Benef its

27

Emergency Serv ices f or Undocumented
Aliens

28

Federally -Qualif ied Health Center

29

Non-Emergency Medical Transportation

30

Phy sical Therapy

31

Occupational Therapy

32

Serv ices f or Speech, Hearing and Language

33

Prosthetic Dev ices, Dentures, Ey eglasses

34

Diagnostic Screening & Prev entiv e Serv ices

34A

Prev entiv e Serv ices Grade A OR B, ACIP
Vaccines and their Admin

35

Nurse Mid-Wif e

36

Emergency Hospital Serv ices

37

Critical Access Hospitals

38

Nurse Practitioner Serv ices

39

School Based Serv ices

40

Rehabilitativ e Serv ices (non-school-based)

41

Priv ate Duty Nursing

42

Freestanding Birth Center

Form CMS 64.9TP Waiver

Medicaid FMAP

Applied Against
the 20% Limit

Deferral or
C.I.N. Number

FMAP

CHIP

(A)
23B

Federal Share

Total
Computable

(B)

Incr. FMAP

(C)

CHIP Amount

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents
Waiver Type:
Waiver Nam e:
Waiver Num ber:

Medicaid and CHIP

Health Home f or Enrollees w Chronic
Conditions

44

Tobacco Cessation f or Preg Women

49

Other Care Serv ices

50

Total

Form CMS 64.9TP Waiver

Applied Against
the 20% Limit

FMAP

Total
Computable

(A)
43

Medicaid FMAP

CHIP

(B)

Incr. FMAP

(C)

CHIP Amount

Deferral or
C.I.N. Number

(D)

(E)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:

Total Computable
Medicaid and CHIP Medicaid FMAP

Waiver Nam e:
Waiver Num ber:

FMAP
CHIP

(A)
1A

Inpatient Hospital Serv ices - Regular Pay ments

1B

Inpatient Hospital Serv ice - DSH Adjustment
Pay ments

1C

Inpatient Hospital Serv ices - Supplemental Pay ments

1D

Inpatient Hospital Serv ices - GME Pay ments

2A

Mental Health Facility Serv ices - Regular Pay ments

2B

Mental Health Facility Serv ices - DSH Adjustment
Pay ments

2C

Certif ied Community Behav ior Health Clinic
Pay ments

3A

Nursing Facility Serv ices - Regular Pay ments

3B

Nursing Facility Serv ices - Supplemental Pay ments

4A

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Public Prov iders

4B

Intermediate Care Facility Serv ices - Ind. with
Intellectual Disabilities: Priv ate Prov iders

4C

Intermediate Care Facility Serv ices - Supplemental
Pay ments

5A

Phy sician and Surgical Serv ices - Regular Pay ments

5B

Phy sician and Surgical Serv ices - Supplemental
Pay ments

5C

Phy sician & Surgical Serv ices - Ev aluation and
Management

5D

Phy sician & Surgical Serv ices - Vaccine codes

6A

Outpatient Hospital Serv ices - Regular Pay ments

6B

Outpatient Hospital Serv ices - Supplemental
Pay ments

7

Prescribed Drugs

7A1

Drug Rebate Of f set - National Agreement

7A2

Drug Rebate Of f set - State Sidebar Agreement

7A3

MCO - National Agreement

Form CMS 64.9T Waiver

Applied Against
the 20% Limit

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:

Total Computable
Medicaid and CHIP Medicaid FMAP

Waiver Nam e:
Waiver Num ber:

FMAP
CHIP

(A)
7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee f or Serv ice - 100%

7A6

Increased ACA OFFSET - MCO - 100%

8

Dental Serv ices

9A

Other Practitioners Serv ices - Regular Pay ments

9B

Other Practitioners Serv ices - Supplemental
Pay ments

10

Clinic Serv ices

11

Laboratory And Radiological Serv ices

12

Home Health Serv ices

13

Sterilizations

14

Abortions No.

15

EPSDT Screening Serv ices

16

Rural Health Clinic Screening

17A

Medicare Health Insurance Pay ments - Part A
Premiums

17B

Medicare Health Insurance Pay ments - Part B
Premiums

17C1

120% - 134% Of Pov erty

17D

Coinsurance And Deductibles

18A

Medicaid Health Insurance Pay ments: Managed Care
Organizations (MCO)

18A1

Medicaid MCO - Ev aluation and Management

18A2

Medicaid MCO - Vaccine codes

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

Form CMS 64.9T Waiver

Applied Against
the 20% Limit

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:

Total Computable
Medicaid and CHIP Medicaid FMAP

Waiver Nam e:
Waiver Num ber:

FMAP
CHIP

(A)
18A5

Medicaid MCO - Certif ied Community Behav ior
Health Clinic Pay ments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Ev aluation and Management

18B1
b

MCO PAHP - Vaccine codes

18B1
c

MCO PAHP - Community First Choice

18B1
d

MCO PAHP - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

18B1
e

Medicaid PAHP - Certif ied Community Behav ior
Health Clinic Pay ments

18B2

Prepaid Inpatient Health Plan

18B2
a

MCO PIHP - Ev aluation and Management

18B2
b

MCO PIHP - Vaccine codes

18B2
c

MCO PIHP - Community First Choice

18B2
d

MCO PIHP - Prev entiv e Serv ices Grade A OR B,
ACIP Vaccines and their Admin

18B2
e

Medicaid PIHP - Certif ied Community Behav ior
Health Clinic Pay ments

18C

Medicaid Health Insurance Pay ments: Group Health
Plan Pay ments

18D

Medicaid Health Insurance Pay ments: Coinsurance
And Deductibles

18E

Medicaid Health Insurance Pay ments: Other

19A

Home and Community -Based Serv ices - Regular
Pay ment (Waiv er)

19B

Home and Community -Based Serv ices - State Plan
1915(i) Only Pay ment

19C

Home and Community -Based Serv ices - State Plan
1915(j) Only Pay ment

19D

Home and Community Based Serv ices State Plan
1915(k) Community First Choice

22

Programs Of All-Inclusiv e Care Elderly

Form CMS 64.9T Waiver

Applied Against
the 20% Limit

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:

Total Computable
Medicaid and CHIP Medicaid FMAP

Waiver Nam e:
Waiver Num ber:

FMAP
CHIP

(A)
23A

Personal Care Serv ices - Regular Pay ment

23B

Personal Care Serv ices - SDS 1915(j)

24A

Targeted Case Management Serv ices - Community
Case-Management

24B

Case Management - State Wide

25

Primary Care Case Management Serv ices

26

Hospice Benef its

27

Emergency Serv ices f or Undocumented Aliens

28

Federally -Qualif ied Health Center

29

Non-Emergency Medical Transportation

30

Phy sical Therapy

31

Occupational Therapy

32

Serv ices f or Speech, Hearing and Language

33

Prosthetic Dev ices, Dentures, Ey eglasses

34

Diagnostic Screening & Prev entiv e Serv ices

34A

Prev entiv e Serv ices Grade A OR B, ACIP Vaccines
and their Admin

35

Nurse Mid-Wif e

36

Emergency Hospital Serv ices

37

Critical Access Hospitals

38

Nurse Practitioner Serv ices

39

School Based Serv ices

40

Rehabilitativ e Serv ices (non-school-based)

41

Priv ate Duty Nursing

Form CMS 64.9T Waiver

Applied Against
the 20% Limit

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:

Medicaid and CHIP Medicaid FMAP

Waiver Nam e:
Waiver Num ber:

FMAP

Total Computable
(A)
42

Freestanding Birth Center

43

Health Home f or Enrollees w Chronic Conditions

44

Tobacco Cessation f or Preg Women

49

Other Care Serv ices

50

Total

Form CMS 64.9T Waiver

Applied Against
the 20% Limit

CHIP

(B)

Incr FMAP

(C)

CHIP Amount
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017
Fraud, Waste & Abuse Amounts Credited
From Medicaid Program Integrity Activities

State:

Medical Assistance Payments

Total
Computable
(A)

Medicaid
(Non-VIII Group)
Federal Share

(B)

Medicaid VIII
Group Federal
Share
(C)

ARRA Federal
Share

BIPP Federal
Share

Federal Share

(D)

(E)

(F)

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

7. Sub-Total
8. Decreasing Adjustments to Amounts Previously
Reported on Line 7
50. Total

Form CMS 64.9C1

Wednesday, September 13, 2017 - 09:22 AM

*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.

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

RECOVERIES FROM OIG STATE COMPLIANT FCA
Medical Assistance Payments

Total
Computable
(A)

1. Recoveries

Medicaid
(Non-VIII Group)
Federal Share
(B)

Medicaid VIII
Group Federal
Share
(C)

ARRA Federal
Share

BIPP Federal
Share

(D)

(E)

Total Federal
Share
(F)

from OIG Certified Compliant FCA

1A. Total Recovery

1B. 10% Reduction FMAP Rate (to be used in the grant
award computation)
1C. 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

Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Allocation of Qualified Individual Part B (QIB) Benefits.
Payment Adjustments to Applicable FFYs
State:

Quarter Ended:
Total Computable
(A)

Federal Share
(B)

FFY 2014 (10/01/2013 - 09/30/2014)
1

FFY 2014 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 2014 Allotment

FFY/CY 2015 (10/01/2014 - 12/31/2015)
1

FFY/CY 2015 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/CY 2015 Allotment

CY 2016 (01/01/2016 - 12/31/2016)
1

CY 2016 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 CY 2016 Allotment

CY 2017 (01/01/2017 - 12/31/2017)
1

CY 2017 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 CY 2017 Allotment

Form CMS 64.9QI

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9PE

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9PE

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9PE

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9PE

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9PE

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9PEP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

Form CMS 64.9PEP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

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

Form CMS 64.9PEP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9PEP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9PEP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9PEP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

Form CMS 64.9PEP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

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

Form CMS 64.9PEP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9PEP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9PEP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9PE Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9PE Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9PE Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9PE Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9PE Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9E

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9E

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9E

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9E

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Special Issue Reporting Program :

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9E

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9EP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

Form CMS 64.9EP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

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

Form CMS 64.9EP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9EP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Special Issue Reporting Program :

Other %
(Oth)

Optional

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9EP

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Form CMS 64.9EP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

Form CMS 64.9EP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

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

Form CMS 64.9EP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Form CMS 64.9EP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share
FMAP

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Eligibility:

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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Form CMS 64.9EP Waiver

Other %
(Oth)

Optional

Total
Comp.

Incr FMAP

(A)

(B)

IHS
Breast or
Facility Fam. Plan Cerv . Cancer
Services Services Serv ices *
90%
100%

(C)

(D)

(E)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9E Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9E Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9E Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9E Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

(A)
43
44
49
50

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Health Home for Enrollees w Chronic
Conditions
Tobacco Cessation for Preg Women

Other Care Services

Total

Form CMS 64.9E Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017
64.S9RAC - RAC Collections
Quarter Ended:

State:

1

Collections Not Previously Reported on CMS-64.9ORAC

2

Collections on Overpayment previously reported on CMS-64.9ORAC

3

Total Collections

4

RAC CONTINGENCY FEES DEDUCTED FROM COLLECTIONS

5

COLLECTIONS LESS FEES

6

LESS PREVIOUSLY REPORTED ON 64.9ORAC. (Line 2)

7

NET COLLECTIONS

Form: CMS 64.S9RAC

Total
Computable

Medicaid
(Non-VIII Group)
Federal Share

Medicaid
VIII Group
Federal Share

ARRA Federal
Share

BIPP Federal
Share

(A)

(B)

(C)

(D)

(E)

Total Federal Share
(F)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Quarterly Medicaid Statement of Expenditures
For the Medical Assistance Program
Summary Sheet
State:

Quarter Ended:

Expenditures Reported for Period
by Form Num ber

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
6.D. From Form CMS-64.9VIII

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
7.D. From Form CMS-64.9VIIIP

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
8.D. From Form CMS-64.9VIIIP

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
10.A.4. From Form CMS-64.9VIIIP

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
10.B.4. From Form CMS-64.9VIIIP

11.

Net Expenditures Reported This Period

12.

Unused CAP

Medical Assistance Payment and Medicaid CHIP

State and Local Administration

Federal Share

Federal Share

(A)

(B)

Form CMS 64 1108CAP

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

(A)

Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Inpatient Hospital Services 1C Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services 2A Mental
Regular Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Community Behavior Health
2C Certified
Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services 3B Nursing
Supplemental Payments
Intermediate Care Facility Services 4A Ind. with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services 4B Ind. with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services 4C Ind. with Intellectual Disabilities:
Supplemental Payments
Physician and Surgical Services 5A Regular Payments
Physician and Surgical Services 5B Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
& Surgical Services - Vaccine
5D Physician
codes
Outpatient Hospital Services - Regular
6A Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs
Rebate Offset - National
7A1 Drug
Agreement

* = Other
Form CMS 64.9VIII

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

(A)

Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Medicare Health Insurance Payments 17A Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)

* = Other
Form CMS 64.9VIII

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

(A)

Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes
Medicaid MCO - Community First
18A3 Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines andtheir
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
MCO PAHP - Preventive Services
18B1
A OR B, ACIP Vaccines and their
d Grade
Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2
MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services
A OR B, ACIP Vaccines and their
d Grade
Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other

* = Other
Form CMS 64.9VIII

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

(A)

Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Home and Community-Based Services
19A
- Regular Payment (Waiver)
Home and Community-Based Services
19B - State Plan 1915(i) Only Payment
and Community-Based Services
19C Home
- State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular
23A Payment
23B Personal Care Services - SDS 1915(j)
Case Management Services 24A Targeted
Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Emergency Services for
27 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
Prosthetic Devices, Dentures,
33 Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B,
34A Preventive
ACIP Vaccines and their Admin

* = Other
Form CMS 64.9VIII

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

(A)

Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

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

* = Other
Form CMS 64.9VIII

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Inpatient Hospital Services 1C Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services - Regular
2A Mental
Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Certified Community Behavior Health
2C Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services - Supplemental
3B Nursing
Payments
Intermediate Care Facility Services - Ind.
4A with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services - Ind.
4B with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services - Ind.
4C with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
Physician & Surgical Services - Vaccine
5D codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs

7A1 Drug Rebate Offset - National Agreement

* = Other
Form CMS 64.9VIII Not Newly

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Health Insurance Payments 17A Medicare
Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
* = Other
Form CMS 64.9VIII Not Newly

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes

18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines and their
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2
MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other
* = Other
Form CMS 64.9VIII Not Newly

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

and Community-Based Services 19A Home
Regular Payment (Waiver)
and Community-Based Services 19B Home
State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Care Services - Regular
23A Personal
Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Services for Undocumented
27 Emergency
Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy
for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B, ACIP
34A Preventive
Vaccines and their Admin
* = Other
Form CMS 64.9VIII Not Newly

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Services
40 Rehabilitative
(non-school-based)
41 Private Duty Nursing

42 Freestanding Birth Center
Home for Enrollees w Chronic
43 Health
Conditions
44 Tobacco Cessation for Preg Women

49 Other Care Services

50 Total

* = Other
Form CMS 64.9VIII Not Newly

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly

Total
Computable

(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Hospital Services 1C Inpatient
Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services 2A Mental
Regular Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Community Behavior Health
2C Certified
Clinic Payments
Nursing Facility Services - Regular
3A Payments
Facility Services 3B Nursing
Supplemental Payments
Intermediate Care Facility Services 4A Ind. with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services 4B Ind. with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services 4C Ind. with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
Physician & Surgical Services - Vaccine
5D codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs
Rebate Offset - National
7A1 Drug
Agreement
* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly

Total
Computable

(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Medicare Health Insurance Payments 17A Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly

Total
Computable

(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes
Medicaid MCO - Community First
18A3 Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines andtheir
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services
A OR B, ACIP Vaccines and their
d Grade
Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
MCO PIHP - Preventive Services
18B2
A OR B, ACIP Vaccines and their
d Grade
Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly

Total
Computable

(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Home and Community-Based Services
19A - 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
Home and Community Based Services
19D 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
Care Case Management
25 Primary
Services
26 Hospice Benefits
27 Emergency Services for
Undocumented Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy
for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B,
34A Preventive
ACIP Vaccines and their Admin

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly

Total
Computable

(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Services
40 Rehabilitative
(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

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Hospital Services 1C Inpatient
Supplemental Payments
Inpatient Hospital Services - GME
1D Payments
Health Facility Services - Regular
2A Mental
Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Certified Community Behavior Health
2C Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services - Supplemental
3B Nursing
Payments
Intermediate Care Facility Services - Ind.
4A with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services - Ind.
4B with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services - Ind.
4C with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
Physician & Surgical Services 5C Evaluation and Management
& Surgical Services - Vaccine
5D Physician
codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

7A1 Drug Rebate Offset - National Agreement
Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Health Insurance Payments 17A Medicare
Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes

18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines and their
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other
and Community-Based Services 19A Home
Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
and Community-Based Services 19C Home
State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Care Services - Regular
23A Personal
Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Services for Undocumented
27 Emergency
Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Preventive Services Grade A OR B, ACIP
34A Vaccines and their Admin
35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Rehabilitative Services
40 (non-school-based)
41 Private Duty Nursing

42 Freestanding Birth Center
Home for Enrollees w Chronic
43 Health
Conditions
44 Tobacco Cessation for Preg Women

49 Other Care Services

50 Total

* = Other
64.9VIII P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

W aiver Type:
W aiver Number:
W aiver Name:
(A)

Total Newly
Federal
Share

Federal Share

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Inpatient Hospital Services 1C Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services 2A Mental
Regular Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Community Behavior Health
2C Certified
Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services 3B Nursing
Supplemental Payments
Intermediate Care Facility Services 4A Ind. with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services 4B Ind. with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services 4C Ind. with Intellectual Disabilities:
Supplemental Payments
Physician and Surgical Services 5A Regular Payments
Physician and Surgical Services 5B Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
& Surgical Services - Vaccine
5D Physician
codes
Outpatient Hospital Services - Regular
6A Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs
Rebate Offset - National
7A1 Drug
Agreement

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

W aiver Type:
W aiver Number:
W aiver Name:
(A)

Total Newly
Federal
Share

Federal Share

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Medicare Health Insurance Payments 17A Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

W aiver Type:
W aiver Number:
W aiver Name:
(A)

Total Newly
Federal
Share

Federal Share

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes
Medicaid MCO - Community First
18A3 Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines andtheir
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
MCO PAHP - Preventive Services
18B1
A OR B, ACIP Vaccines and their
d Grade
Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2
MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services
A OR B, ACIP Vaccines and their
d Grade
Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Medicaid Health Insurance Payments:
18C Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

W aiver Type:
W aiver Number:
W aiver Name:
(A)

Total Newly
Federal
Share

Federal Share

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Home and Community-Based Services
19A
- Regular Payment (Waiver)
Home and Community-Based Services
19B - State Plan 1915(i) Only Payment
and Community-Based Services
19C Home
- State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Personal Care Services - Regular
23A Payment
23B Personal Care Services - SDS 1915(j)
Case Management Services 24A Targeted
Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Emergency Services for
27 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
Prosthetic Devices, Dentures,
33 Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B,
34A Preventive
ACIP Vaccines and their Admin

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:
Type of Eligibility:

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program Expenditures In This Quarter
Total
Computable

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

W aiver Type:
W aiver Number:
W aiver Name:
(A)

Total Newly
Federal
Share

Federal Share

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Expires 12/31/2017
Quarter Ended:
Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)
(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

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

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Inpatient Hospital Services 1C Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services - Regular
2A Mental
Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Certified Community Behavior Health
2C Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services - Supplemental
3B Nursing
Payments
Intermediate Care Facility Services - Ind.
4A with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services - Ind.
4B with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services - Ind.
4C with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
Physician & Surgical Services - Vaccine
5D codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs

7A1 Drug Rebate Offset - National Agreement

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Health Insurance Payments 17A Medicare
Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes

18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines and their
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2
MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

and Community-Based Services 19A Home
Regular Payment (Waiver)
and Community-Based Services 19B Home
State Plan 1915(i) Only Payment
Home and Community-Based Services 19C State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Care Services - Regular
23A Personal
Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Services for Undocumented
27 Emergency
Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy
for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B, ACIP
34A Preventive
Vaccines and their Admin

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017

For The Medical Assistance Program Expenditures In This Quarter
State:
Type of Eligibility:

Quarter Ended:
Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP
Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

(B)

(C)

(D)

Other
%*
Optional
Breast or
Cervical
Cancer*
(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
Special
s Applied to
Newly COL J Circumstance COL K
(K)
(L)
(M)

35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Services
40 Rehabilitative
(non-school-based)
41 Private Duty Nursing

42 Freestanding Birth Center
Home for Enrollees w Chronic
43 Health
Conditions
44 Tobacco Cessation for Preg Women

49 Other Care Services

50 Total

* = Other
64.9VIII Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly
W aiver Type:

Total
Computable

W aiver Number:
W aiver Name:
(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Hospital Services 1C Inpatient
Supplemental Payments
Hospital Services - GME
1D Inpatient
Payments
Health Facility Services 2A Mental
Regular Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Community Behavior Health
2C Certified
Clinic Payments
Nursing Facility Services - Regular
3A Payments
Facility Services 3B Nursing
Supplemental Payments
Intermediate Care Facility Services 4A Ind. with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services 4B Ind. with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services 4C Ind. with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
& Surgical Services 5C Physician
Evaluation and Management
Physician & Surgical Services - Vaccine
5D codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs
Rebate Offset - National
7A1 Drug
Agreement
* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly
W aiver Type:

Total
Computable

W aiver Number:
W aiver Name:
(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
Not Newly
X Newly %
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Medicare Health Insurance Payments 17A Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly
W aiver Type:

Total
Computable

W aiver Number:
W aiver Name:
(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes
Medicaid MCO - Community First
18A3 Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines andtheir
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services
A OR B, ACIP Vaccines and their
d Grade
Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
MCO PIHP - Preventive Services
18B2
A OR B, ACIP Vaccines and their
d Grade
Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments
Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly
W aiver Type:

Total
Computable

W aiver Number:
W aiver Name:
(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

Home and Community-Based Services
19A - 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
Home and Community Based Services
19D 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
Care Case Management
25 Primary
Services
26 Hospice Benefits
27 Emergency Services for
Undocumented Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy
for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Services Grade A OR B,
34A Preventive
ACIP Vaccines and their Admin

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Type of Eligibility:
Newly
W aiver Type:

Total
Computable

W aiver Number:
W aiver Name:
(A)

Line:
Total Newly
Federal
Share

Federal Share

Newly FMAP

I.H.S
Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Other
%*

Federal
Share
(F)

(G)

Federal
Total
Total Comp
Share
Computable Federal Share Applied from Enrollment
Resource Test Resource Test Not Newly Cap applied
Applied from Applied COL H Enrollment
COL J X
X Newly %
Not Newly
Cap
Newly
(H)
(I)
(J)
(K)

Total
Computable Federal Share
Applied from
Special
Not Newly Circumstance
Special
applied COL L
Circumstance X Newly %
(L)

(M)

Sum of
Sum of Total
Federal
Computables
Shares
Column (A) + Column (G) +
(H) + (J)+ (L) (I) + (K) + (M)
(N)
(O)

35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Services
40 Rehabilitative
(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

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

Hospital Services - Regular
1A Inpatient
Payments
Hospital Service - DSH
1B Inpatient
Adjustment Payments
Hospital Services 1C Inpatient
Supplemental Payments
Inpatient Hospital Services - GME
1D Payments
Health Facility Services - Regular
2A Mental
Payments
Health Facility Services - DSH
2B Mental
Adjustment Payments
Certified Community Behavior Health
2C Clinic Payments
Facility Services - Regular
3A Nursing
Payments
Facility Services - Supplemental
3B Nursing
Payments
Intermediate Care Facility Services - Ind.
4A with Intellectual Disabilities: Public
Providers
Intermediate Care Facility Services - Ind.
4B with Intellectual Disabilities: Private
Providers
Intermediate Care Facility Services - Ind.
4C with Intellectual Disabilities:
Supplemental Payments
and Surgical Services 5A Physician
Regular Payments
and Surgical Services 5B Physician
Supplemental Payments
Physician & Surgical Services 5C Evaluation and Management
& Surgical Services - Vaccine
5D Physician
codes
Hospital Services - Regular
6A Outpatient
Payments
Hospital Services 6B Outpatient
Supplemental Payments
7 Prescribed Drugs

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

7A1 Drug Rebate Offset - National Agreement
Rebate Offset - State Sidebar
7A2 Drug
Agreement
7A3 MCO - National Agreement

7A4 MCO - State Sidebar Agreement
ACA OFFSET - Fee for
7A5 Increased
Service - 100%
7A6 Increased ACA OFFSET - MCO - 100%

8 Dental Services
Practitioners Services - Regular
9A Other
Payments
Practitioners Services 9B Other
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
Health Insurance Payments 17A Medicare
Part A Premiums
Health Insurance Payments 17B Medicare
Part B Premiums
17C1 120% - 134% Of Poverty

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

17D Coinsurance And Deductibles
Health Insurance Payments:
18A Medicaid
Managed Care Organizations (MCO)
MCO - Evaluation and
18A1 Medicaid
Management
18A2 Medicaid MCO - Vaccine codes

18A3 Medicaid MCO - Community First Choice
Medicaid MCO - Preventive Services
18A4 Grade A OR B, ACIP Vaccines and their
Admin
MCO - Certified Community
18A5 Medicaid
Behavior Health Clinic Payments
18B1 Prepaid Ambulatory Health Plan
18B1 MCO PAHP - Evaluation and
a Management
18B1 MCO PAHP - Vaccine codes
b
18B1 MCO PAHP - Community First Choice
c
18B1 MCO PAHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B1 Medicaid PAHP - Certified Community
e Behavior Health Clinic Payments
18B2 Prepaid Inpatient Health Plan
18B2 MCO PIHP - Evaluation and
a Management
18B2 MCO PIHP - Vaccine codes
b
18B2 MCO PIHP - Community First Choice
c
18B2 MCO PIHP - Preventive Services Grade
d A OR B, ACIP Vaccines and their Admin
18B2 Medicaid PIHP - Certified Community
e Behavior Health Clinic Payments

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

Health Insurance Payments:
18C Medicaid
Group Health Plan Payments
Health Insurance Payments:
18D Medicaid
Coinsurance And Deductibles
Health Insurance Payments:
18E Medicaid
Other
and Community-Based Services 19A Home
Regular Payment (Waiver)
Home and Community-Based Services 19B State Plan 1915(i) Only Payment
and Community-Based Services 19C Home
State Plan 1915(j) Only Payment
Home and Community Based Services
19D State Plan 1915(k) Community First
Choice
22 Programs Of All-Inclusive Care Elderly
Care Services - Regular
23A Personal
Payment
23B Personal Care Services - SDS 1915(j)
Targeted Case Management Services 24A Community Case-Management
24B Case Management - State Wide
Care Case Management
25 Primary
Services
26 Hospice Benefits
Services for Undocumented
27 Emergency
Aliens
28 Federally-Qualified Health Center

29 Non-Emergency Medical Transportation

30 Physical Therapy

31 Occupational Therapy

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services

OMB No. 0938-1265

Centers for Medicare & Medicaid Services
State:

Medical Assistance Expenditures By Type Of Service

Expires 12/31/2017
Quarter Ended:

For The Medical Assistance Program Expenditures In This Quarter

Fiscal Year:
Line:
Type of Eligibility:

Federal Share
Total
Computable

W aiver Type:
W aiver Number:
W aiver Name:
(A)

FMAP

Other
%*

Incr FMAP

I.H.S Facility
Services

Family
Planning
Services

Optional
Breast or
Cervical
Cancer*

(B)

(C)

(D)

(E)

Federal
Share

(F)

Adjusted Total
Comp from
Col B Not
Total Comp
Total Comp
Newly
Resource Test
Enroll Cap
Applied to
Applied to
Newly Col B X
Newly Col H X
(G)

(H)

(I)

Adjusted Total
Comp from
Col B minus
Resource Test
Col G minus
Enrollment
Cap COL I
(J)

Adjusted Total Comp
from COL B minus Total Federal
Total Comp Resource Test COL
Share
Special
G Minus Enrollment
Circumstance CAP COL I minus
s Applied to
Special
Newly COL J Circumstance COL K
(K)

(L)

(M)

for Speech, Hearing and
32 Services
Language
Devices, Dentures,
33 Prosthetic
Eyeglasses
Screening & Preventive
34 Diagnostic
Services
Preventive Services Grade A OR B, ACIP
34A Vaccines and their Admin
35 Nurse Mid-Wife

36 Emergency Hospital Services

37 Critical Access Hospitals

38 Nurse Practitioner Services

39 School Based Services
Rehabilitative Services
40 (non-school-based)
41 Private Duty Nursing

42 Freestanding Birth Center
Home for Enrollees w Chronic
43 Health
Conditions
44 Tobacco Cessation for Preg Women

49 Other Care Services

50 Total

* = Other
64.9VIII Waiver P

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

Form CMS 64.10 200K

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration - 200K
For the Medical Assistance Program
Expenditures In This Quarter
State:

Quarter Ended:
Federal Share
Total
Computable
(A)

49

Other Financial Participation

50

Total

Form CMS 64.10 200K

FFP
Rate

Federal
Share
(B)

0.0%

Federal
Share
(C)

Total
Federal
Share
(D)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration - 200K
for the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
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%)

16

TANF Secondary (75%)

17

External Review

18

Enrollment Brokers

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration - 200K
for the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Total
Computable
(A)
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

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

28E

Eligibility Determination Staff – Cost of In-house
Activities

28F

Eligibility Determination Staff – Cost of Private Sector
Contractors

28G

Eligibility Determination Staff – Cost of In-house
Activities – 50% FFP

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Expenditures for State and Local Administration - 200K
for the Medical Assistance Program
Prior Period Adjustments
Quarter Ended:
Prior Fiscal Year:

State:
Line #
Federal Share
Total
Computable
(A)
28H

Eligibility Determination Staff – Cost of Private Sector
Contractors – 50% FFP

29

Non-Emergency Medical Transportation

49

Other Financial Participation

50

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

DSH Allotm ent 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(C)

(D)

(E)

Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(B)

Other & Prompt Pay
Other %
(Oth)

Inpatient Hospital Services - GME Payments

2A

4B

(A)

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9 WAIV DSH Diversion

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

DSH Allotm ent Year:
7A4
7A5
7A6
8

14
15
16

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(G)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(F)

Clinic Services

17A

17C1

(E)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(D)

Federal Share

Increased ACA OFFSET - MCO - 100%

9B

12

(C)

Prompt Pay
(PP)

Total
Federal
Share

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(B)

Other & Prompt Pay
Other %
(Oth)

MCO - State Sidebar Agreement

9A

10

(A)

FMAP

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

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

Form CMS 64.9 WAIV DSH Diversion

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

DSH Allotm ent Year:

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9 WAIV DSH Diversion

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

DSH Allotm ent Year:
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9 WAIV DSH Diversion

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

State:

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures In This Quarter
Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:

Optional

Total Comp.

DSH Allotm ent Year:
43
44
49
50

(A)

FMAP

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other & Prompt Pay
Other %
(Oth)
Prompt Pay
(PP)

Federal Share

(F)

Total
Federal
Share

(G)

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

DSH Allotm ent Year:
1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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 - National Agreement

7A2

Drug Rebate - State Sidebar Agreement

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9P WAIV DSH Diversion

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

DSH Allotm ent Year:
7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

13

Sterilizations

14

Abortions

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9P WAIV DSH Diversion

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

DSH Allotm ent Year:
18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9P WAIV DSH Diversion

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

DSH Allotm ent Year:
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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9P WAIV DSH Diversion

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:

DSH Allotm ent Year:
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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9P WAIV DSH Diversion

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures in This Quarter

State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess

Optional

Total Comp.
Expenditure

DSH Allotm ent 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular
Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Public Providers

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: 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

(B)

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Intermediate Care Facility Services - Ind.
with Intellectual Disabilities: Private
Providers

4C

7

(A)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

Inpatient Hospital Services - GME Payments

2A

4B

FMAP

Prescribed Drugs

Drug Rebate Offset - National Agreement

Drug Rebate Offset - State Sidebar
Agreement
MCO - National Agreement

Form CMS 64.9I DSH Diversion Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures in This Quarter

State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess

Optional

Total Comp.
Expenditure

DSH Allotm ent Year:
7A4
7A5
7A6
8

14
15
16

(G)

Home Health Services

Sterilizations

Abortions No.

EPSDT Screening Services

Rural Health Clinic Screening

17B

Medicare Health Insurance Payments - Part
B Premiums

18A

(F)

Laboratory And Radiological Services

Medicare Health Insurance Payments - Part
A Premiums

17D

(E)

Clinic Services

17A

17C1

(D)

Dental Services

Other Practitioners Services - Supplemental
Payments

13

(C)

Federal Share

Total
Federal
Share

Increased ACA OFFSET - MCO - 100%

9B

12

(B)

Other %
(Oth)

Increased ACA OFFSET - Fee for Service 100%

Other Practitioners Services - Regular
Payments

11

(A)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

MCO - State Sidebar Agreement

9A

10

FMAP

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

Form CMS 64.9I DSH Diversion Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures in This Quarter

State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess

Optional

Total Comp.

FMAP

Expenditure

DSH Allotm ent Year:

(A)

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

Medicaid MCO - Certified Community

18A5 Behavior Health Clinic Payments
18B1
18B1
a
18B1
b
18B1
c

Prepaid Ambulatory Health Plan

MCO PAHP - Evaluation and Management

MCO PAHP - Vaccine codes

MCO PAHP - Community First Choice

MCO PAHP - Preventive Services Grade A

18B1 OR B, ACIP Vaccines and their Admin
d
Medicaid PAHP - Certified Community

18B1 Behavior Health Clinic Payments
e
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
Medicaid PIHP - Certified Community

18B2 Behavior Health Clinic Payments
e
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

Programs Of All-Inclusive Care Elderly

Personal Care Services - Regular Payment

Form CMS 64.9I DSH Diversion Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures in This Quarter

State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess

Optional

Total Comp.
Expenditure

DSH Allotm ent Year:
23B
24A
24B
25
26
27
28
29
30
31
32
33
34
34A
35
36
37
38
39
40
41
42

FMAP

(A)

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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

Form CMS 64.9I DSH Diversion Waiver

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medical Assistance Expenditures By Type Of Service
For The Medical Assistance Program
Expenditures in This Quarter

State:

Quarter Ended:
Federal Share

Medical Assistance Paym ents
Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess

Optional

Total Comp.
Expenditure

DSH Allotm ent Year:
43
44
49
50

FMAP

(A)

(B)

IHS Facility Fam. Plan.
Breast or
Services
Services Cerv . Cancer
100%
90%
Serv ices

(C)

(D)

(E)

Other %
(Oth)

Federal Share

(F)

Total
Federal
Share

(G)

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: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess Expenditure
DSH Allotm ent Year:
1A

Inpatient Hospital Services: Regular Payments

1B

Inpatient Hospital Services: 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

2C

Certified Community Behavior Health Clinic
Payments

3A

Nursing Facility Services - Regular Payments

3B

Nursing Facility Services - Supplemental
Payments

4A

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Public Providers

4B

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: Private Providers

4C

Intermediate Care Facility Services - Ind. with
Intellectual Disabilities: 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

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9PI DSH Diversion Waiver

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess Expenditure
DSH Allotm ent Year:
7A3

MCO - National Agreement

7A4

MCO - State Sidebar Agreement

7A5

Increased ACA OFFSET - Fee for Service 100%

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

15

EPSDT Screening Services

16

Rural Health Clinic Services

17A

Medicare Health Insurance Payments: Part A
Premiums

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

18A1

Medicaid MCO - Evaluation and Management

18A2

Medicaid MCO - Vaccine codes

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9PI DSH Diversion Waiver

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess Expenditure
DSH Allotm ent Year:
18A3

Medicaid MCO - Community First Choice

18A4

Medicaid MCO - Preventive Services Grade A
OR B, ACIP Vaccines and their Admin

18A5

Medicaid MCO - Certified Community Behavior
Health Clinic Payments

18B1

Prepaid Ambulatory Health Plan

18B1
a

MCO PAHP - Evaluation and Management

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

18B1
e

Medicaid PAHP - Certified Community
Behavior Health Clinic Payments

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

18B2
e

Medicaid PIHP - Certified Community Behavior
Health Clinic Payments

18C

Medicaid Health Insurance Payments: Group
Health Plan Payments

18D

Medicaid Health Insurance Payments:
Coinsurance and Deductibles

18E

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

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9PI DSH Diversion Waiver

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess Expenditure
DSH Allotm ent Year:
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

T argeted 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

28

Federally-Qualified Health Center

29

Non-Emergency Medical T ransportation

30

Physical T herapy

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

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9PI DSH Diversion Waiver

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

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 Paym ents

Federal Share

Waiver Type:
Waiver Num ber:
Waiver Nam e:
Program : DSH Excess Expenditure
DSH Allotm ent Year:
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

T obacco Cessation for Preg Women

49

Other Care Services

50

T otal

Other & Prompt Pay

Total
Comp.

FMAP

(A)

(B)

Form CMS 64.9PI DSH Diversion Waiver

IHS
Facility
Services
100%

(C)

Optional
Breast or
Fam. Plan Cerv . Cancer
Services Serv ices *

90%

(D)

(E)

Other %
(Oth)
Prompt Pay
(PP)

Federal
Share
(F)

Total
Federal
Share

Deferral
Or
C.I.N.
Number

(G)

(H)

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Enrollees
State:
Eligible Categories

Quarter Ended:
July
CY 2016

August
CY 2016

September
CY 2016

October
CY 2016

November
CY 2016

December
CY 2016

January
CY 2017

February
CY 2017

March
CY 2017

April
CY 2017

May
CY 2017

June
CY 2017

Total

(A)

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(I)

(J)

(K)

(L)

(M)

Medicaid Eligibles
I. VIII Gr oup Eligibles
1. Newly Eligible
1A

Parent/Caretaker
Relatives

1B

Childless Adults

1C

Total Newly
Eligible

2. Not Newly Eligible
2A

Parent/Caretaker
Relatives

2B

Disabled Person
NonInstitutionaliz ed

2C

Disabled Person,
Institutionaliz ed

2D

Children Age 19 to
20

2E

Childless Adults

2F

Other

2G

Total Not Newly
Eligible

3

VIII Group Total
Eligibles

II. Aged/Blind or Disabled
4

Aged

5

Blind or Disabled

Form CMS 64.ENROLL

Report Date: Wednesday, September 13, 2017 - 09:22 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 12/31/2017

Medicaid Enrollees
State:
Eligible Categories

Quarter Ended:
July
CY 2016

August
CY 2016

September
CY 2016

October
CY 2016

November
CY 2016

December
CY 2016

January
CY 2017

February
CY 2017

March
CY 2017

April
CY 2017

May
CY 2017

June
CY 2017

Total

(A)

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(I)

(J)

(K)

(L)

(M)

Medicaid Eligibles
III. Other Eligibles
6

Children

7. Other Adults (Non-Disabled/N on Aged) Non VIII Group
7A

Pregnancy Benefit
Adults

7B

All Other Adults
not included
above

7C

Total Other Adults

8

Total Eligibles

Form CMS 64.ENROLL

Report Date: Wednesday, September 13, 2017 - 09:22 AM


File Typeapplication/pdf
File Title64 Blank Forms
AuthorREBECCA HENSLEY
File Modified2017-09-27
File Created2017-09-26

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