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pdfDepartment 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 Type | application/pdf |
| File Title | 64 Blank Forms |
| Author | REBECCA HENSLEY |
| File Modified | 2017-09-27 |
| File Created | 2017-09-26 |